When it comes to diseases, make a habit of two things-to help, or at least to do no harm. The Hippocratic Oath taken by most physicians upon entering the medical profession also states that clinicians should, "declare the past, diagnose the present, foretell the future; practice these acts." If only the same oath asked them to document their actions clearly, completely and within 24 hours!

This month's column focuses on the physician's role in RAC. From physician advisers to specific education needed regarding clinical documentation and RAC, this month we'll explore the various issues and opportunities involving medical staff.

Finding a Physician Adviser
One of the first steps is the assignment of a physician adviser to the RAC team. The medical specialty of this team member matters less than their ability to be objective, supersede organizational politics and understand medical necessity. This physician should be available for reference on RAC issues and easily accessible to review cases during the appeal process.

Similar to the political challenges of a Medical Staff Director or Vice President of Medical Affairs, the RAC physician adviser will face numerous trials in working with his or her peers. Because of this reason, many organizations outsource a physician adviser for RAC and several firms offer these services. Whether outsourced or a member of your in-house staff, the RAC physician adviser is an important first step in a successful RAC program and once in place, can help with the second step-physician education.

Nancy Hirschl, CCS	Lori Brocato

Educating Physicians about RAC
According to the American Health Information Management Association (AHIMA), educating the medical staff is an important component of developing a successful RAC program. In their RAC Toolkit, AHIMA suggests that medical staff should: 

"Receive an overview of the RAC program and how it impacts the health care entity and where they may be impacted in terms of documentation practices. In addition, since individual providers will also be subject to RAC request, education can help them understand how their own office staff will be impacted and what they will need to do in preparation."

One way to emphasize to medical staff how they might be impacted by RAC is to remind them that when hospitals get reviewed by RACs for certain procedures, they may be next! An easy example to cite involved urologists who administered prostate cancer drugs in their offices during the demonstration project. Specifically, injectable or implantable drugs administered between 2002 and 2003. Some urologists were asked to repay as much as $30,000.¹

While the American Urological Association and others were able to intervene and adjust RAC demands in their favor, these events can be used as an example of the down-river impact to physicians when RACs begin knocking at hospital doors. Similarly, short-stay patients are under extreme scrutiny under the RAC program. If Medicare reimbursement for a short-stay admission or inappropriate inpatient procedure is retracted by the RAC, there is high likelihood the professional fee charges for the same short-stay admission or inappropriate inpatient procedure will also be retracted by the Medicare Administrative Contractor (MAC).

The bottom line for medical staff is that not only will hospital Medicare reimbursement be impacted by RAC, but there is a good chance their personal, professional fee reimbursements will be retracted as well.  This news, in combination with reports from the demonstration project, should perk the ears of physicians and give HIM directors the ammunition they need to get physicians engaged and on-board with RAC.

Picking Your Battles
Just like marital and parenting relationships, it's often wise to pick your battles. From a physician education perspective, HIM directors can "pick" their battles when it comes to RAC-focused education and clinical documentation improvement. One known area of RAC investigation is cardiac defibrillators.

Working with the cardiology department, HIM directors can focus clinical documentation improvement initiatives on patients who have a cardiac defibrillator implanted as an inpatient vs. an outpatient. Millions of dollars were denied during the demonstration project for cardiac defibrillators implanted as an inpatient procedure. While many of these were overturned at the Administrative Law Judge (ALJ) level, the lessons learned are vitally important:

1.      Educate physicians that cardiac defibrillators should be performed as outpatients.

2.      If performed as an inpatient, all pertinent risk factors should be well-documented in the medical record. While there is no guarantee that the RAC may accept an inpatient status, your chances for approval and/or appeal success are greater if risk factors are well-documented.

3.      Read and understand the Heart Rhythm Society (HRS) hospitalization criteria for cardiac defibrillators.

According to the HRS, in-patient status is warranted for patients who require more intensive monitoring, intravenous hydration, medication titration and extended nursing or physician care. Patients with post procedure complications are also best managed as an inpatient status. Eight specific conditions that warrant inpatient status are listed by the HRS and can be easily shared with your cardiology department.

Getting physicians on board with any HIM or clinical documentation initiative has always been a challenge for HIM! RAC will be no exception. By enlisting the help of a strong physician adviser, using examples from the demonstration project, and focusing your efforts, getting physician on board with RAC may be easier than you think!

Visit our column next month as we begin to explore RAC appeals, how to determine if the appeal process is worth it, and which appeals to pursue.

Reference
1. Kerr, Richard. "California LHRH case holds lessons for all urologists". 2007. Urology Times. Advanstar Communications. Available online at: http://urologytimes.com/.

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.