Medicare Compliance & Reimbursement

Discover the top diagnoses and procedures where RACs are aiming their sites.

Getting burned by RAC audits ruled against your favor when you know your facility was in the right? The devil is in the details, and your documentation is likely the culprit. 

“There are two elements to better documentation,” says Deepak Pahuja, MD, FACP, CEO and chief medical officer for Aerolib Healthcare Solutions and member of the American College of Physician Executives, “the framework and the architecture.” 

First, is following all the guidelines in the CMS Integrity Manual (e.g., having 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.) 

“That’s just the framework; now the architecture needs to be complete,” Pahuja says. So, for the second portion, it’s a matter of filling those bullet points, or framework, with the appropriate, detailed content. 

Check out the following three examples, provided by Pahuja, to get a better understanding of where documentation is falling short — and what RACs are targeting:

Example 1: TIA versus CVA

TIAs are the most audited diagnoses in all 4 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 mis-documenting a true CVA.

As far as 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.

“A lot of it has to do with semantics,” Pahuja says. “CMS is very particular about words that they like.” For instance, the chief complaint of weakness and numbness in the left hand “is a good chief complaint, but it’s lacking the medical necessity details that auditors look for.”

A better note might say, “weakness and numbness in patient’s left hand and slurred speech that started at 2 pm today and lasted for four hours,” Pahuja says. That’s enough information to suggest a TIA, and you could treat and bill accordingly.

If, however, a patient presents with the above symptoms, but they are continuing to happen, that can be considered a CVA because the symptoms have not resolved, Pahuja says. “Due to the higher mortality rate of CVAs, the expected length of stay is three and a half days — so you could admit that patient right now rather than put them under observation for 24 hours and then switch them to inpatient,” Pahuja says.

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. 

“This happens even though the hospital is doing exactly the right thing: the patient is under telemetry, they’re giving her some form of anticoagulation, they have the neuro checks, etc.; it just boils down to the fact that we do a poor job of documenting these details to paint the picture of how severe this patient is,” Pahuja says.

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

Example 2: Knee Replacement Surgeries

Knee replacements are a hot spot for audits, mainly because they are an elective procedure — so the medical decision-making behind them must be crystal-clear on paper and sufficiently support why it was necessary. To add more fuel to the auditing fire, these procedures can be high-risk (due to the average age of the patient receiving knee replacements), and they are very expensive — around $25,000. 

All this said, Medicare is looking for whether this was a spur-of-the-moment decision, or a carefully considered procedure after trying other options, according to Pahuja.

Important considerations: You should have a solid three months’ worth of documentation on your interventions and the patient’s responses, Pahuja recommends. “What’s failed in conservative treatment (e.g. medicine, physical therapy)? What was the patient’s response? How do you think the knee replacement will help this patient, in terms of better mobility, activities of daily living, and quality of life?” Pahuja says. The answers to these questions need to be clearly stated in the patient’s file.

Example 3: AICD Implantations

Automatic Implantable Cardioverter Defibrillators (AICDs) and the implantation procedure carries, on average, the hefty price tag of $35,000, making this a standard red flag for auditors. Medicare, with the help of the American College of Cardiologists, has developed criteria for covering this procedure, and you can be sure that RACs are following it closely.

“It’s high risk for the patient, expensive for Medicare, and a huge cost burden if unnecessary AICDs are put in, so they have strict criteria on what the heart function should be, what the physician should have done prior to considering the patient for the device (e.g. failure to respond to medical therapy) — and unless that is documented, Medicare will not pay for it,” Pahuja says.

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

Pahuja notices that cardiologists are relatively good in ordering echocardiograms, but they do not demonstrate enough reflection on how the patient had responded to non-operative therapy prior to the AICD procedure. “As an auditor,” he says, “I look for the last three months in outpatient and hospital notes on what the physician did for this patient to preserve heart function, versus just jumping into that procedure.”