Q&A: RAC, medical necessity, and the role of CDI

With the RAC focusing heavily on medical necessity are CDI programs shifting to put more time toward documentation to capture the medical necessity, or is that the job of case management? 

A: CDI members should have access to and review the PEPPER reports to compare how their facility “stacks up” against the benchmarks. Take a look at the focus items listed on that report and see if you are performing better or worse than the national average.

 

For example, if you are reporting a higher percentage of complex pneumonia cases, it would be in your best interest to audit those records to make sure that the documentation and the resources supports that diagnosis. Since the PEPPER focus diagnoses are also RAC targets, you should develop a “second-review” process for each of those records prior to final coding and billing: review by another coder and/or your physician advisor (who is experienced in CDI) to make sure that all the elements are in the record (documentation, resources).

 

I think the role of CDI is to capture accurate documentation. Period. Of course, that does not exclude communicating issues to the care manager—whose role is concerned with medical necessity—when appropriate. For example, “hey, I reviewed this chart and the current principal diagnosis of unspecified syncope is unlikely to support the medical necessity for an inpatient stay.”  Or: “this patient was admitted with ‘chest pain’ and all the cardiac tests are normal.  I’ve queried for the cause of the chest pain, so maybe you could help follow up on this one since the current documentation may not support medical necessity.” 

 

Although there should definitely be synergy between CDI and case management, I think each group has a defined purpose, and we shouldn’t be involved in issues that we are not clearly responsible for. This is what makes blended CDI/CM models so tricky—you’re trying to be responsible for everything and the provider gets confused about your primary role.

 

Editor’s Note: Lynne Spryszak, RN, CPC-A, CCDS, CDI education director for HCPro, Inc., in Danvers, MA, answered this question. Contact her at lspryszak@hcpro.com. For more information about how to use PEPPER read the April edition of the CDI Journal. Join HCPro for the audio conference “PEPPER 2011: Identify Changes, Address Vulnerabilities, and Be Audit-Ready,” featuring ACDIS advisory board members Donna D. Wilson, RHIA, CCS, CCDS and Cheryl Ericson MS, RN.