Carol Richardson, Director, Health Information Management, Adventist Health, Donna D. Wilson, Senior Director, Compliance Concepts, Inc. and Susan Bihler, Director of Utilization Management, Florida Hospital weighs in on utilizing RACs for process improvement and how hospitals are acquiring information for at-risk documentation.

HFMA: How are hospitals using RAC as process improvement - for example, is it making an impact on how hospitals do clinical documentation? What can you do to improve that area?

CR: RAC scrutiny is one of a variety of good reasons for healthcare providers to pursue clinical documentation improvement. Over the past two years our Adventist Health facilities have evaluated the potential gains in implementing and staffing formal CDI programs, and several of them are well on their way in measuring outcomes. Our system has also secured ongoing consultant support in concurrent and retrospective medical necessity determinations. In addition, Adventist Health continues a regular, monthly coder education program which commenced in 2006.

DW: Yes, RAC is forcing hospitals to implement some much needed process improvement methods such as more uniformity in the physician order sets. The correct patient status is crucial when the RAC begins reviewing for medical necessity-Outpatient, Observation or Inpatient. Hospitals can review all existing order sets to determine if they are still valid. Confiscate orders from the intranet, hospital floors, physician offices, etc. to determine if they include a valid patient status. Also from a clinical documentation standpoint, coders and CDI professionals can work together in analyzing current RAC denials for coding. For example, if excisional debridement is being denied within a facility the CDI professional should work with the physician on proper documentation so the coders can assign the appropriate code.

SB: I do not know that I would quantify the RAC as a process improvement exercise specifically, but I would say that the measures and practices that RAC looks at have been the same that we have looked and make sure that we are compliant with the CMS guidelines and are using these practices across all of our 8 campuses.

HFMA: Are there any barriers to process improvement within the hospital related to RAC that nobody talks about?

CR: While facility-level budgetary constraints may need to be overcome initially in obtaining outside assistance, we have found that all our entities have made the commitment to assimilating these process improvements going forward. We value all efforts to quickly identify and rectify any inadvertent step which might result in an incomplete or incorrect claim.

DW: Sure process improvement methods take quite a bit of time and resources-not to mention constant education! The barriers would be the lack of staff to keep the momentum of consistent best practice process improvement methods. Teaching facilities have multiple providers that rotate in and out of practice-so finding the best way to educate and followup is quite a challenge.

SB: There are times where the CMS/RAC guidelines are not clear and therefore we must make some assumptions on our part. Also, there are some rule changes or billing changes as the result of RAC that are not clearly defined and therefore this does cause some barriers.

HFMA: Where do you get the information for at-risk documentation?

CR: Areas of potentially at-risk documentation are easily accessible in the approved focus areas posted on RAC websites, facility PEPPER data which resumed with third quarter 2009, and published OIG work plan targets. Logging and trending physician coding queries at the facility level can be very helpful in illuminating areas of insufficient physician documentation. Documented trends offer areas in which coding and clinical documentation improvement staff can collaborate in designing specific interventions.

DW: We worked on this for an AHIMA Audio seminar entitled: Auditing your RAC Results. 

SB: We do get information from CMS and the RAC in regard to "at-risk" documentation, but frankly, we know what is medically sound and appropriate documentation, and we adhere to this no matter who the payer is. We do know that CMS requires certain documentation sets that other payers may not such as: Place in Observation or Admit to IP, and we definitely adhere to this documentation standard and teach our medical staff to do the same.

Publication Date: Friday, May 14, 2010