Guest Post: Tips for new Recovery Audit program denial defense

CDI Blog - Volume 10, Issue 14

By Laura Legg, RHIT, CCS, CDIP

CMS recently announced the award of a new round of contracts for the Medicare fee-for-service Recovery Auditors (RA). As the new round of RAs roll out, even the most experienced RA response team will need to understand the new challenges we face with CMS’ 2017 changes. Make every effort to ensure your teams are centralized, efficient and organized with excellent communication skills. Also, it is very important to educate your RA response team on changes to the RA rules. Following are a few tips to help you stay on top of the changes.

Compose complete medical records: Your facility should include all required documentation necessary to support each case. If a physician orders a test, make sure the order, results, and interpretation are all included with the medical record and are legible and easily found. Also make sure the discharge summary is as complete as possible. The discharge summary should accurately reflect all confirmed diagnoses and all care administered during the patient’s hospital stay without introducing new information.

Avoid EHR cloning: Cloning, or copy and paste, is being seriously addressed by CMS. RAs may be looking at progress notes for confusion among caregivers due to copy and paste overuse.

Focus on challenging inpatient diagnoses: What diagnoses and procedures challenge coders the most? Some tricky diagnoses are, but are not limited to, sepsis, respiratory failure, renal failure, congestive heart failure, pneumonia, spinal surgeries, and skin procedures. Make sure the medical record documentation support these diagnoses and that coders can easily identify the correct code assignment for them.

Follow RA websites: CMS requires RAs  to keep an updated provider portal which includes a list of issues under review. This resource shows the issue name, type of review, provider type, status impacted, date posted and a detailed description of the issue. It is a good idea to build your internal audit plan around this list and the Office of Inspector General’s (OIG) work plan. CMS will require RAs to broaden their review topics and they must include all provider claim types and may include required reviews based on referrals from the OIG report.

Audit: Be sure that all diagnoses are coded to the highest level of specificity. Ensure that all medical documentation entries are consistent. Be sure internal auditors look at the same data elements reviewed by the RA including principal diagnosis, secondary diagnosis, procedures affecting or potentially affecting diagnosis-related groups, present on admission indicators, and discharge disposition codes.

Reduce denial rates—Under the new rules, additional documentation request (ADR) rates will be affected by your denial rate. More denials will result in more requests and denials still mean a lot of work on the provider end and a drawn-out appeals process. You can improve response rate and efficiency simply by following RA timelines and responding to record request appropriately. Takebacks due to lack of response to ADRs are more common that you think.

Editor’s Note: Legg is the director of HIM optimization at Healthcare Resource Group in Spokane Valley, Washington. This article was adapted from the original published in JustCoding.com. Opinions expressed are that of the author and do not represent HCPro or ACDIS.