Nancy Hirschl, CCS	Lori Brocato

While everyone knows the recipe for RAC success doesn't begin and end with one ingredient, clinical coding is the secret sauce that pulls it all together. Clinical coding is the key component HIM directors bring to the mix and is one of the essential pieces of an integrated RAC strategy that is completely under their control.  

However, with almost half of all overpayments collected during the demonstration project as the result of incorrect coding, the pressure is on for HIM directors and clinical coders. The two must work together to ensure coding is correct and compliant -- particularly for known RAC targets like wound debridement, lysis of adhesions, respiratory failure, sepsis and coagulation disorders. This month we'll explore HIM's most important ingredient for a well-baked RAC strategy: compliant clinical coding.

Coding Compliance: Know Your Issues
As mentioned in our last column, CMS has pushed out the timeline for RAC complex reviews for DRG validation and coding until later this year.¹ First wave states have a slight reprieve, and savvy HIM directors should take this time to re-evaluate coding compliance and consider second level reviews. RAC coding reviews should focus on what we already know:

• Chronic coding and clinical documentation issues specific to your organization.
• RAC targets identified during the demonstration project.

Earlier columns explored how to use existing reports such as the PEPPER reports and case mix results to identify areas of coding weakness. In addition, simply ask your coders what cases are most difficult to code and which areas of clinical documentation are lacking. Finally, check-out what the Office of Inspector General or quality improvement organizations are currently evaluating. You don't need software to identify some of these common sense problems -- just a little insight and education.

From there, it may be prudent to designate a senior coder as "RAC Coding Specialist." This coder could educate peers on specific RAC coding issues, assist with second level reviews and serve as a liaison between the organization's RAC team and the clinical coders.

Finally, there are five known RAC targets that involve coding. Each one warrants additional focus -- especially now that HIM directors have the time!  

Fine Tuning the Recipe: Focused Areas for Coding
According to the American Health Information Management Association (AHIMA), the demonstration project identified five key areas of improper payment due to incorrect inpatient coding²:

In last month's column, we explored excisional debridement and provided some practical advice for improving clinical documentation and coding outcomes in this area. The bottom line for debridement is that clinical documentation must meet the requirements of the American Hospital Association's (AHA) Coding Clinics to be assigned procedure code 86.22. If the documentation doesn't support excisional debridement, the non-operative code of 86.28 should be used. When in doubt, coders should query the physician to clarify the type and extent/depth of the debridement procedure performed. This simple coding error alone cost demonstration project providers between $5,000 and $15,000 each in Medicare take-backs.

Each of the target areas listed have clear-cut and well-documented recommendations for improvement along with simple coding compliance suggestions. Many include improvements in clinical documentation and collaboration with physicians; a topic we'll further explore next month. 

Finally, HIM directors may want to consider hiring an outside coding agency or audit firm to conduct second level reviews and RAC-focused audits. This may be particularly helpful for organizations short on coding staff or coding manager resources. The return on investment for an outside coding audit could be significant when RAC complex reviews begin later this year.

Be Accountable
From an executive perspective, holding everyone accountable for their part of the process is one of the leading RAC challenges. Coding compliance is one area where HIM directors and coding teams are truly accountable -- and can truly shine! That is as long as they have clear and adequate clinical documentation. Stay tuned next month as we discuss ways to engage physicians in the process, develop stronger physician relationships, and ultimately win physician cooperation with RAC initiatives.  

Lori Brocato is currently the revenue cycle management product manager for HealthPort. Nancy Hirschl is president and CEO of Hirschl and Associates, Laguna Niguel, CA.