Inpatient Facility Coding & Compliance Alert

Learn from the 3 top targeted documentation mistakes people make.

Your best defense when auditors arrive to scour your records is airtight documentation. Use these three examples to avoid audit landmines. 

Basics: Does your documentation incorporate all the guidelines in the CMS Integrity Manual? Remember you need to have a full admission order, a dated order, a diagnosis, the condition of the patient, the HPI, chief complaint, review of systems, a full history, a full examination, and a full medical decision making. 

Keeping this in mind, check out the following three examples to get a better understanding of where documentation is falling short — and what the auditors are likely to target:

Example 1: TIA versus CVA

Transient ischemic attacks (TIAs) are the most audited diagnoses in all four Medicare regions, according to Comprehensive Error Rate Testing (CERT) data. Hospitals can lose a lot of money paying Medicare back for an unnecessary hospital admission for a TIA; but they can also lose a lot of money for misdocumenting a true cerebrovascular accident (CVA).

In terms of DRGs, CMS could fork over $5,000 for a CVA, as opposed to $2,500 for a TIA, so it’ll be as picky as ever to make sure your hospital admission is justified.

Because CMS has targeted inpatient status, many people have thought that following the “2 Midnights Rule” (introduced in the 2014 Inpatient Prospective Payment System) would keep them in the clear … but if support for medical necessity falls short, not so much. 

“Regardless of any rules, regulations, and/or guidelines, medical necessity continues as the overarching compliance issue in healthcare”, highlights Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA.

A good chief complaint should hint at the medical necessity too, such as, “weakness and numbness in patient’s right hand and slurred speech that started at midnight and lasted for six hours.” This documentation suggests a TIA, and justifies the subsequent treatment and billing.

If, however, a patient presents with the above symptoms, which do not show signs of resolution over a time period, that hints at CVA. 

Common problem: You admit a patient as a TIA. She eventually deteriorates to CVA status, so you keep the patient for three days and submit the bill as a CVA. The entire stay is justified, but the growing severity of the patient and her final diagnosis is not documented appropriately to support the hospital admission. 

Resource: See page 9 and 10 in the following MLN newsletter on audit findings on TIA billing errors: http://tinyurl.com/l3j65dn. 

Example 2: Knee Replacement Surgeries

Knee replacements are a favorite of auditors, mainly because they are an elective procedure — so the medical decision-making supporting them must be crystal-clear on paper and be medically necessary. Not to mention that this procedure can be high-risk, and very expensive (around $25,000). 

Be ready to justify that the decision was a well-considered and an inevitable one. Back it up with good preoperative documentation of your previously performed conservative interventions, and how they could not suffice. Also mention how you expect this patient to have a good postoperative prognosis in terms of recovery, better mobility, and quality of life.

 “Keep in mind that preoperative documentation may span several different physicians or providers,” reminds Abbey.

Example 3: AICD Implantations

Automatic implantable cardioverter defibrillators (AICDs) and the implantation procedure are expensive too ($35,000 approximately), making this a well sought record for auditors. Medicare, with the help of the American College of Cardiologists, has developed criteria for covering this procedure.

Prepare yourself for the same rationale as that of knee replacement: Be sure to document the specific reasons for your decision to opt for such a potentially high risk and expensive procedure. 

Do not forget to mention your earlier interventions and how you reached the medical decision that the patient needs to resort to device eventually.

Plus: To read CMS’ national coverage determination on implantable automatic defibrillators, visit http://tinyurl.com/mx62gyb.