Guest Post: Santa’s not the only one watching to see if you’ve been bad or good

by Sylvia Hoffman, RN

Singing: He sees you when you’re sleeping. He knows when you’re awake. He knows if you’ve been bad or good, so be good for goodness sake.

Remind you of anyone? No? Here’s a hint. It rhymes with knick-knack but these groups aren’t known to be particularly “nice.”

Audit contractors (Recovery Audit Contractors or RACs) are not Santa, but they are watching you, and they certainly know if you’ve been naughty.

Let’s be realistic, all of your facility healthcare data is being scrutinized, analyzed, and compared. Statistical data gives audit contractors an idea of which hospitals fall off the bell curve, and what diagnosis qualify as low hanging fruit.

If your hospital has a 30% sepsis admission rate and all other hospitals in your area have a 10% rate, then you pretty much are going to stand out like a sore thumb. Do not fool yourselves. It is not because your CDI department is that much better at capturing sepsis as a diagnosis.

Take a look at how your facility does business and whether it may be pushing the envelope when it comes to leading queries and creative coding. Does your hospital follow AHIMA’s recommendations when it comes to formulating compliant queries?  The brief clearly states that:

“Individuals who perform the query function should be familiar with the AHIMA Standards of Ethical Coding, which direct coders to assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.”

Next, review and update your own internal policies and procedures. Many hospitals create these policies and then never check to make sure the rules are being followed. The AHIMA guidance states:

“Individuals performing the query function should follow their healthcare entity’s internal policies related to documentation, querying, coding, and compliance, keeping in mind that data accuracy and integrity are fundamental HIM values. Only diagnosis codes that are clearly and consistently supported by provider documentation should be assigned and reported. A query should be initiated when there is conflicting, incomplete, or ambiguous documentation in the health record or additional information is needed for correct assignment of the POA indicator.”

Lastly, create an audit process to ensure that both your own policies and AHIMA recommendations are being followed. Healthcare entities should consider establishing an auditing and monitoring program as a means to improve their query processes. They can consider several methods for this ongoing process. Queries can be reviewed retrospectively to ensure that they are completed according to documented policies. This might include reviewing determining whether the:

• query was necessary
• language used in the query was not leading or otherwise inappropriate
• query introduced new information not otherwise included in the medical record

Based on the results of this review, the healthcare entity may need to identify specific corrective actions. For example, any cases identified as containing inappropriate queries which resulted in inaccurate code assignment will require corrective action and possibly rebilling. Inappropriate queries should be tracked, trends identified, and appropriate education, training, and/or disciplinary action taken when warranted.

No one wants to get a lump of coal in their stocking. And no one wants to give the RAC or other auditor a Christmas bonus. Take time this holiday season to make some New Year resolutions and ensure that your facility is compliant and knowledgeable. You will then reap the rewards of a stocking filled with peace of mind.

Editor's note: Hoffman, at the time of this article's original release, was a CDIS in Tampa Florida. She had been a nurse for more than 20 years and enjoys writing, painting, and travelling.