Nancy Hirschl, CCS	Lori Brocato

The connection between clinical documentation, coding and recovery audit contractors (RACs) is actually much stronger than you might expect. As HIM professionals prepare for RAC reviews and audits, a solid working relationship with clinical documentation improvement (CDI) experts and participation in their programs is essential. Case managers are also an important part of the equation and should be included in all CDI conversations -- especially where RAC is concerned. By joining up with CDI and case managers, HIM professionals can shore up documentation and reduce RAC risk.

As an example, we learned from the RAC demonstration project that certain diagnosis and procedures will be targeted for overpayment. Based on this knowledge, HIM professionals, CDI experts and case managers can pinpoint physician education and documentation improvement efforts. This article uses two of these targeted areas, wound debridement and short stays, to describe how HIM professionals find strength in numbers and can take another step toward RAC success.

Battling a Costly Enemy: Wound Debridement
During the RAC demonstration project, payment for wound debridement inpatient procedures resulted in a combined $18 million in Medicare take-backs. Many of the demonstration hospitals were hit hard for this one procedure alone! In a recent Webinar conducted by the American Health Information Management Association (AHIMA)¹, specific examples of wound debridement issues were explained as follows:

• Coder assigns a procedure code of 86.22 based on physician documentation of "wound debridement performed."
• Coding Clinic 1991, Q3, states "Unless the attending physician documents in the medical record that an excisional debridement was performed (definite cutting away of tissue, not the minor scissors removal of loose fragments), debridement of the skin should be coded to 86.26, non excisional debridement of skin. Any debridement of the skin that does not meet the criteria noted above or is described in the medical record as debridement and no other information is available should be coded as 82.26."
• The RAC determined that the claim was INCORRECTLY CODED and issued a repayment request letter for the difference between the payment amount for the incorrectly correctly coded procedure and the payment amount for the correctly coded procedure.

As we prepare for the permanent program, HIM professionals can safely assume wound debridement will again be a target for the RAC and an important area for teaming up with CDI counterparts. Corrective actions should include education at all levels: physicians, coders and billing staff. An ongoing CDI program for wound debridement should be implemented to include concurrent review of the surgeon's documentation and a well-written physician query with in-depth questions about the procedure. Finally, pre-billing reviews may be considered for all claims containing wound debridement.

Observation patients must include documentation in two areas:  

• Physician must have written an order for observation including justification for observation status.
• Patient must meet observation criteria.

Conversely, patients who were admitted must also meet criteria. One RAC, Connelly Consulting, has gone so far as to specify patients must meet McKesson's InterQual Level of Care criteria for admission and is recommending a copy of the InterQual admission guidelines be sent with each request, if available.

Certain circumstances are commonly reviewed. The biggest problem area is with surgery patients. Often these patients are admitted overnight for observation, but may not meet admission criteria. Case managers are responsible for completing InterQual forms based on the physician's documentation; therefore both parties must be apprised of the RAC risk: case managers and medical staff.

Lean on Your Team
The battle against RAC won't be won single-handedly. HIM professionals must take advantage of every available resource to prepare for and manage RAC demands. Existing CDI professionals and case managers are important allies in this quest. A new association, the Association of Clinical Documentation Improvement Professionals, is available to help and provides valuable tools specifically focused on RAC. Likewise, the Case Management Society of America offers a number of educational programs that HIM professionals may find advantageous as part of an overall RAC readiness plan.

Tune in next month to understand how the current economic downturn is impacting HIM's ability to balance coding compliance with RAC demands.