By Lisa A. Eramo
Eighty-nine percent of hospitals are experiencing Recovery Auditor (RA) activity, according to RACTrac data from the third quarter 2012.
“If you’re audited, you will be denied,” says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources in Newton Square, Pa. “To go for a zero denial rate shouldn’t be what you strive for. Your goal should be to provide good patient care and submit an accurate claim that’s supported by appropriate documentation both from the UM/coding perspective as well as from the clinical perspective.”
In August 2012, CMS launched its RA prepayment demonstration project, which marks the addition of yet another review to the agency’s ever-expanding list.
The project, which runs through August 2015, targets 11 states:
- California
- Florida
- Illinois
- Louisiana
- Michigan
- Missouri,
- North Carolina
- New York
- Pennsylvania
- Ohio
- Texas
The project focuses on claims with high improper payment rates—particularly short inpatient stays (i.e., inpatient stays with a duration of fewer than two days).
RAs are currently performing prepayment MS-DRG validation and coding reviews of MS-DRG 312 (syncope and collapse). They will perform similar reviews of the following additional MS-DRGs using a phased-in approach:
- 069, transient ischemia
- 377, GI hemorrhage with MCC )
- 378, GI hemorrhage with CC
- 379, GI hemorrhage without CC or MCC
- 637, diabetes with MCC
- 638, diabetes with CC
- 639, diabetes without CC or MCC
“[These MS-DRGs] are consistent with what we’re seeing in terms of the lion’s share of complex denials by all of the contractors,” says Wuebker.
The percent of claims that will be reviewed as part of the RA prepayment demonstration is unknown at this time, says Wuebker. “It’s unclear whether they’re going to review 100% of your DRG 312 or 10% as well as which hospitals are going to be selected for different percentages,” he adds.
Some MACs are already performing prepayment reviews of many of the MS-DRGs listed above, says Wuebker. For example, Cahaba Government Benefit Administrators and First Coast Service Options are currently performing prepayment reviews of MS-DRG 069.
Although 2011-12 included a substantial expansion of auditor activity, 2013 may bring additional challenges for hospitals, says Wuebker. “Unfortunately, I think 2013 may prove to be the year of extrapolation,” he says. “We’re starting to see more of what I would call the bad audits—the OIG, DOJ, and ZPICs—where there’s accusations of criminal activity and frank fraud.”
MS-DRG 312
It’s important to review Program for Evaluating Payment Patterns Electronic Report (PEPPER) data to identify short stays—particularly for MS-DRG 312—and drill down into the documentation, says Stacey Levitt, RN, MSN, CPC, senior managing consultant with Berkeley Research Group in Washington, DC.
Syncope (i.e., a transient loss of consciousness due to transient global cerebral hypoperfusion) is a common complaint for ED visits, and it leads to 6% of hospital admissions in the United States, says Levitt.
ICD-9-CM code 780.2 denotes syncope and collapse. This includes:
- Blackout
- Fainting
- Near (pre) syncope
- Vasovagal attack
It excludes:
- Carotid sinus syncope (337.0))
- Heat syncope (992.1))
- Neurocirculatory asthenia (306.2))
- Orthostatic hypotension (458.0)
- Shock NOS (785.50)
According to the ICD-9-CM Official Guidelines for Coding and Reporting, coders should not report codes for symptoms, signs, and ill-defined conditions from Chapter 16 (e.g., 780.2) as a principal diagnosis when the provider has established a related definitive diagnosis.
However, documentation isn’t always clear as to why the episode occurred and what, if any, related definitive diagnoses may be present. Syncope may signify life-threatening conditions for patients over the age of 60, says Levitt. However, for nearly 50% of syncope admissions, patients are discharged within 48 hours with unresolved syncopal etiology, she adds.
Levitt says coders and clinical documentation improvement specialists should ask the following questions before coding syncope:
- Is this true syncope, or does some other serious condition account for the patient’s loss of consciousness (e.g., stroke, seizure, or a head injury)?
- If the patient truly has syncope, is there a clear life-threatening cause?
- If the patient truly has syncope—and the cause isn’t clear—is the patient still considered high risk?
“You really need to push for documentation of the high-risk piece,” says Levitt.
Physicians must document a detail history and physical that includes the following:
- Patient’s age and any associated cormorbidities
- Cardiac risk factors, including a personal history of cardiac disease, family history of sudden cardiac death, and the presence of heart failure
- Electrocardiogram results, including any abnormal results
- Orthostatic blood pressure measurement, including persistently low blood pressure
- Shortness of breath with event or during evaluation
- Hematocrit less than 30
- Other treatments, such as serial troponin testing, 12-24 hours of cardiac monitoring, and selective echocardiographic testing
ED case managers should screen syncope cases for complete documentation of risk stratification for an inpatient admission, including adverse outcome probability, says Levitt. They can also help coders determine whether condition code 44 is appropriate, she adds.
Editor’s note: The content in this article was originally presented during HCPro’s audio conference Proactively Defend Against Recovery Auditor Prepayment Reviews. To learn more or to purchase a copy of this audio, visithttp://www.hcmarketplace.com/prod-11032/Proactively-Defend-Against-Recovery-Auditor-Prepayment-Reviews.html.