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AR Systems, Inc Training Library Presents

AR Systems, Inc Training Library Presents. What’s New with MAC, RAC, Medicaid and the OIG? Audit findings, Updates, and Operational Ideas Instructor: Day Egusquiza, Pres AR Systems, Inc . Goal of the Audit Culture.

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AR Systems, Inc Training Library Presents

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  1. AR Systems, Inc Training Library Presents What’s New with MAC, RAC, Medicaid and the OIG?Audit findings, Updates, and Operational Ideas Instructor: Day Egusquiza, Pres AR Systems, Inc RAC 2012

  2. Goal of the Audit Culture • To ensure billed services are reflected in the documentation in the record • To ensure billed services are in the medically correct setting for the pt’s condition • To ensure billed service reflect the ‘rules’ regarding billing for the specific service • To ensure documentation can support all billed services according to the payer rules. RAC 2012

  3. Outline of Audit Findings • Common issues: • Dept staff not understanding the charge capture must match physician order and documentation. • Lack of ongoing coder education • Lack of ongoing dept head ed • Lack of physician understanding • Creating a culture of audit – time to be pro-active RAC 2012

  4. National Error RateSummer 2010 - 12.4%; 2011-10.5%-8.5% • Commitment to Reduce the Error • President Obama recently announced the government’s commitment to reduce the error rate by 50% (using a baseline of 12.4%) by 2012 (2008 3.6% $10.3 Billion ) • – 9.5% for November 2010 Report • – 8.5% for November 2011 Report • – 6.2% for November 2012 Report • Thru MAC, CERT, ZPIC, RAC, MIC, OIG, HEAT auditing… • Funding PPACA by eliminating fraud, waste and abuse… RAC 2012

  5. CMS Claim’s Review EntitiesRoles of Various Medicare Improper Payment ReviewsTimothy Hill, CFO , Dir of Office on Financial Mgt9-9-08 presentation RAC 2012

  6. Updates Impacting the Auditing of Claims RAC 2012

  7. Jan 2012 RAC updates –Building on 2011 – 3 goals Demonstration Pre-Payment Review –focused • 7 states with high fraud and error prone providers: FL, CA, TX, MI, NY, LA, Ill • 4 states with high volume of short stay hospital stays: PA, OH, NC. MO • Does not replace Pre for MACs • Should allow for more timely rebills of corrected claims while catching potential patterns early.REACTIVATED: Go live June 2012 Prior authorization of certain medical equipment. (www/cms/gov/apps/media/ Press/factsheet.asp?counter Part A to Part B Rebilling • 380 hospitals /pilot can sign up to volunteer • All hospitals to resubmit claims for 90% of the allowable Part B payment when RAC, CERT, MAC finds that a Medicare pt met Part B, not Part A. • NO APPEAL RIGHTS if join this demonstration project. • Can opt out at any time. (www/cms/gov/apps/media/ RAC 2012

  8. Pre-Payment Expanded Info Dec 2011 – Prepayment CMS calls • Limitations on prepayment won’t exceed current post payment ADR limits. • Medical records provided on appeal will be remanded to the RAC for review • Claims will be off limits from future post payment reviews • ADR letter will advise where to send: RAC or MAC. • 30 days to reply • June 1 – 312/Syncope • Aug 1 – 069/Transcient Ischemia; 377/GI hemorrhage w/MCC • Sept 1 – 378/GI Hemorrhage w CC; 379/GI Hemorrhage w/o CC/MCC • Oct 1 – 637/diabetes w/MCC; 638/diabetes w/CC; 639/diabetes w/o CC/MCC RAC @cms.hhs.gov //go.cms.gov/cert-demos RAC 2012

  9. Updated Statement of Work 9-11 • Highlights • Allows /outlines Semi Automated Reviews • RAC decisions beyond 60 days = no payment to the RAC but can request an extension. • Discussion period continues but no timelines for replies from the RAC. Should be in writing and responded to within 30 days of receipt. If appeal is filed, discussion period ends. • Posting of new issues still a problem with HDI and Connolly. But no new guidelines for the RACs • Timely period between results letter and demand letter . (Estimated at 2 weeks) (CMS’s website, posted 9-1-11) RAC 2012

  10. New 45 day record countwww.cms.gov/recovery-audit-program/downloads/providers_adrlimit-Update_03-12.pdf • Effective March 15, 2012, calculation for record count has increased. • “The limit is equal to 2% (use to be 1%) of all claims submitted for the previous calendar year divided by 8. EX) billed 156,253 claims, 2% = 3125 /8 = 390 every 45 days” • “RAC can request up to 35 records per 45 days for providers whose calculated limit is 34 or less” • “Maximum # of records per 45 is 400” (was 300) • “Providers with over $100,000,000 in MS-DRG payments who had the 500 requests cap will now have a 600 record cap” • Hospital feedback on 3-16: GA “went up 118%; Al doubled, Texas up by 100 records each 45 days, NC up by 87 records, IN 300-400 between our 3 hospitals.” RAC 2012

  11. Updated SOW –Semi • Semi-automated reviews are a two-part review that is now being used in the Recovery Audit Program. The first part is the identification of a billing aberrancy through an automated review using claims data. This aberrancy has a high index of suspicion to be an improper payment. The second part includes a Notification Letter that is sent to the provider explaining the potential billing error that was identified. • Still no limit on requests; in addition to complex record requests. RAC 2012

  12. CMS Quarterly Newsletter, June 2011 RAC 2012

  13. Top Issues per Region, CMS, 3Q 2011 • Region A: Renal and Urinary Tract Disorders (Not medically appropriate for inpt status) • Region B: Extensive Operating room procedures unrelated to principal dx (DRG validation – primary and 2nd dx errors) • Region C: Durable Medical Equipment/Prosthetics/DMEPOS (Automated review – no separate payment when inpt.) • Region D: Minor surgery and other treatment billed as an inpt (Not medically appropriate for an inpt status.) • HDI purchased by NY based HMS Holdings $400M. 11-11 RAC 2012

  14. CMS Quarterly Newsletter – *Based on collected amts thru Sept 30, 2011 RAC 2012

  15. Top Issues per Region/9-2011 • Region A: Renal & Urinary Tract Disorders (medically necessary/incorrect setting) • Region B: Surgical Cardiovascular Procedures (medically necessary) • Region C: Acute inpt admission neurological disorders (medically necessary) • Region D: Minor surgeries and other treatment billed as an inpt (medically necessary ) *When pts with known dx enter a hospital for a specific minor surgical procedure and is expected to keep them les than 24 hrs, they are considered outpt regardless of the hour they present to the hospital, whether a bed was used or whether they remain after midnight. RAC 2012

  16. Change with Demand letters-HUGE CR 7436, MM Matters7436 • After many confusing/delayed RAC recovery and demand letters, CMS has made the following change. • “Effective Jan 3, 2012, CMS is transferring the responsibility for issuing demand letters to providers from its Recovery Auditors to its claims processing contractors. This change was made to avoid any delays in demand letter issuance. As a result, when a Recovery Auditor finds that improper payments have been made to you, they will submit claim adjustments to your Medicare contractor. Your Medicare contractor will then establish receivables and issue automated demand letters for any RAC identified overpayment. The Medicare contactor will follow the same process as is used to recover other overpayments. The Medicare contractor will then be responsible for fielding any administrative concerns you may have with timelines, appeals, etc.” • Messy: Letter to MAC/FI’s contact, not the RAC contact. Yell ! • Details as to the reason/pt identifier are missing. Not required. RAC 2012

  17. Patient Protection and Affordable Care Act, March 23, 2010 • Focusing on curbing fraud, waste and abuse in the Medicare program. • Time period for filing Medicare FFS claims in Section 6404 of the PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service. • Under the new law, claims for services furnished on or after Jan 1, 2010 must be filed within 1 calendar year after date of service. In addition, mandates that claims for services furnished before Jan 1, 2010 must be filed no later than Dec 31, 2010. • The following rules apply to claims with dates of service prior to Jan 1, 2010: claims with dates of service before Oct 1, 2009 must follow the pre-PPACA timely filing rules. Claims with dates of service Oct 1-Dec 31, 2009 must be submitted by Dec 31, 2010. • Impact on denied claims with rebill potential with the RAC and MIC? • MESSAGE: GET IT RIGHT THE FIRST TIME. RAC 2012

  18. More Pt Protection and Affordable Act (PPACA)“Most of the healthcare reform can be paid for by finding savings within the existing health care system, a system that is currently full of waste and abuse.” Pres. Obama • Requires report and repayment of overpayments. • “Overpayment’ = funds a person receives or retains to which person is not entitled after reconciliation. • Providers and suppliers must: Report and return overpayments to HHS, the state or contractor by the later of: • 60 days after the date the overpayment was identified or • The date the corresponding cost report is due. Provide a written explanation of the reason for overpayment (PPACA 6402) Retaining overpayments after the deadline for reporting is subject to False Claims Act and Civil Monetary Penalties law. RAC 2012

  19. CMS series w/ MedLearnwww.cms.gov/RAC • SE1024 “RAC: High Risk Vulnerabilities- No documentation or insufficient documentation submitted” (July 2010) • Two areas of high risk were identified from the demonstration project: No reply to request/timely submission (1 additional attempt must be made prior to denial) Incomplete or insufficient documentation to support billable services RAC 2012

  20. Additional CMS/MedLearn Training • SE1024/July     No documentation or insufficient documentation submitted • SE1027/Sept    Medical necessity vulnerabilities for inpt hospitals •  SE1028/Sept    DRG coding vulnerabilities for inpt hospitals • SE1036/Dec Physician RAC vulnerabilities • SE1037 /Jan 11 Guidance on Hospital Inpt Admission (referencing CMS guidelines, does not mandate Interqual/Milliman, RAC judgment allowed) • SE1104/Mar 11 Correct Coding POS/Physicians • Special Edition #SE1121/June 11 RAC DRG Vulnerabilities –coding w/o D/C summary • SE1210/Mar 12 RAC with MN of Renal & Urinary Tract Disorders RAC 2012

  21. CMS reiterates guidance on inpt admission determinations SE 1037, 2-3-11 • CMS refers hospitals to Medicare Program Integrity Manual and reiterates that CMS requires contractor staff to use a screening tool as part of their medical review process of inpt hospital claims. While there are several commercially available screening tools…such as Milliman, Interqual and other PROPRIETARY systems… CMS does not endorse any particular brand. • CMS repeats that contractors are not required to automatically pay a claim even if screening indicates the admission was appropriate and conversely, contractors are not automatically to deny claims that do not meet screening tool guidelines • “In all cases, in addition to the screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the record.” • The guidance restates that the Medicare Benefit Policy Manual, Chpt 1, instructions that a physician is responsible for deciding whether the pt should be admitted as inpt. RAC 2012

  22. Only physician’s can …. • Determining correct status • Clarifying order of the status • Examples of weak orders: Admit to Dr Joe, Admit to tele, Transfer to the floor, admit to 23:59, admit to medical service, admit to FIT. None clearly define : Admit to inpt status and why –add (intent of the order) • Directing the clinical team as to the intensity of services that need provided when the pt ‘hits the bed’ as well as thru the course of treatment. • 42 CFR 482.12 (c) (2) “Patients are admitting to the hospital only on a recommendation of a licensed practitioner permitted by the state to admit pts to the hospital. “ • Medicare State Operations Manual “In no case may a non-physician make a final determination that a pt’s stay is not medically necessary or appropriate.” Case Mgt protocol can ‘recommend’ to the providers but only takes effect when the provider has authenticated it. RAC 2012

  23. If a non-attending/admitting… • Many facilities are using outside physician advisors or are growing their own advisors – many times the UR physician. • Ensure that any 2nd opinion by a non-treating provider is ‘validated’ and used for directing care by the attending/admitting. Otherwise it is just another non-treating opinion. Additionally, look for educational opportunities thru patterns --dx, documentation, doctor. • Double check with the QIO for their opinion during audit. RAC 2012

  24. ADR plus PIP hospitals • 2-11 CMS announced a revised threshold for hospitals with $100 million in Medicare payments. The cap was raised to 500 per 45 day period, up from the 300 cap. AHA expressed concern over the 87 hospitals that will be impacted by this change. (New #, 3-12, 600) • PIP hospitals will begin to have records requested 2nd Q 2012.. Many PIP hospitals are large hospitals who could easily have their first record request be 500 records. RAC 2012

  25. Semi –Automated Claims Review • All RACs have begun doing (4-11) • Using the automated review/data mining to identify billing abnormalities with a high potential for improper payment. • This is followed by a request for records/complex to audit to determine if an error did occur in charge capture or claim’s submission. • EX) Tx hospital: Cataract removal can occur once per eye for the same date of service. 66984/removal with insertion of lens AND 67010-59 removal with mechanical vitrectomy) created the edit. 59 overrode edits = 2 payments. RAC 2012

  26. More Semi Automated Examples • Connolly, 5-11 • Remicade billed w/chemo drug adm CPT codes • Letter says: “Data analysis showed an aberrant billing pattern inconsistent with a policy. “ • Unknown limit, not subject to complex limits • Connolly, 5-11 • Letter for at least 100 claims. • Infliximab –is a monoclonal antibody agent. Drugs “may’ be administered using the chemo therapy CPTs. • Reply with records within 45 days, same penalities RAC 2012

  27. Physician/Non PP Additional Documentation Limits • As of 2-14-11, modified changes • Limits based on physician or non PP’s billing Tax ID # as well as the first three positions of the ZIP code where that physician/non PP is physically located. • EX: Group ABC has TIN 12345 and two physical locations in ZIP code 4567 and 4568. This group qualifies as a single entry for additional documentation requests/ADR. • Ex: Group XYZ has TIN 12345 and two physical locations in ZIP 4556 and 5566. This group would qualify as two unique entities for ADR RAC 2012

  28. More on Physician ADR • ADR limits will be based on the # of individual rendering physician/non-PP reported under each TIN/ZIP combination in the previous calendar year. Reserves the right to exceed the cap if indicated. RAC 2012

  29. Physician Focus Areas • Place of Service – outpt hospital vs office (SE1104 Med Learn; 11 vs 22 or 23) • Separate E&M leveling within the surgical/CPT bundle period • New vs Established • Level of service conflicts with the hospital – doc /inpt; hospital/OBS • Based on CERT audit results/ West coast, the following was targeted for audit: (2011) • 99214 • 99223 (Initial day) • 99233 (Subsequent hospital visit) • Cert audits can trigger requests for records if provider history shows an abnormal volume/risk for targeted CPT codes • Office E&M leveling is not a focus of the RAC audits..yet RAC 2012

  30. MACs are auditing … w/CMS moving from 15 to 11 MACS • …can be the same material as the RACs. • Ex. Az hospital had a ST MUE error. They received automated demand letters from HDI; however, they also received ‘first notice’ from WPS on the same issue. Per WPS, the site has 30 days from receipt of the WPS letter without interest to repay or be recouped on the 41st day with interest. • No published items; no limits on requests, same appeal rights. Letters SOMETIMES explain.. • WPS – Prepayment 310, 313, 192, 690 • NHIC – Prepayment auditing of Chest pain, syncope and collapse, CHF. RAC 2012

  31. More MAC audits • Noridian/J3 has announced Probe audits for AZ, MT, ND, SD, UT, WY • Probe for 1 day stays, 2 day stays, 3 day stays and high dollar (w/o definition of $) • Noridian was awarded JF MAC on 8-22-11 Includes ID, ND, Alaska, WA, Ore, SD, MT, WY, UT and AZ. Look for more wide spread auditing. Using CERT data for more probes • NGS – Mobile CMS audits/NY & Prepayment (2012) No letters with reasons. RAC 2012

  32. And more MAC auditing • Highmark (Now Novitas Solutions) • Probe for DRG 470/Major Joint Replacement or reattachment of lower extremity w/MCC. Need to document 6 months of failed conservative therapy!! • Probe for DRG 244 Permanent Cardiac Pacemaker implant w/o CC or MCC. • NEW: 313, 392, 292 (2012) • Msg from provider: Have been having 100% prepayment audit payment for DRG 313/chest pain for almost 2 years now. The site indicates they are being successful around 90% of time at the 3rd level appeal/ALJ but it is taking about 18 months. There does not appear to be a change with the pre-payment review even with the overturn rate. (per PA facility history 9-11) RAC 2012

  33. And more MAC • Trailblazer/TX highlights • Developed LCD 41-96SAB for Hydration (96360-61) • Reviewing DRG appeals and determining patient status was incorrect. Denied entire inpt stay. • Issued 5 DRGs that will be on prepayment review: 243, 246, 247, 460, 470 (Ex: Stents, pacemaker) • 2011- Lost MAC bid. Highmark awarded. 1/12 – Highmark ‘s Medicare Division , MAC J12, was sold to BC/BC of FL (BCBSF) with their subsidiary, First Coast who is a MAC J9. RAC 2012

  34. MACs are beefing up prepayment auditing –with physician impact • Trailblazer: to increase consistency in Medicare reimbursement, effective 11-11, Trailblazer will begin cross-claim review of these services. The related Part B service (E&M, procedures) reported to Medicare will be evaluated for reimbursement on a post payment basis. Overpayments will be requested for services related to the inpt stay that are found to be in error. • First Coast & HighMark/Novitas– similar RAC 2012

  35. More MAC auditing • Palmetto, Pre Payment Auditing • Began early 2012 • DRGs focus: • 871 Septicemia/Sepsis • 641 Misc disorders of nutrition • 690 Kidney / UTI • 470 Joint replacement Site: CA site. Prior to Feb, 2012 – never had a pre-payment audit request. Had 12 in 1st request. RAC 2012

  36. And more MAC – AL hospital Cahaba – Pre-Auditing of the below DRGs. (2-12) • 069 (Transient Ischemia) • 191      (Chronic Obstructive Pulmonary Disease w CC) • 195      (Simple Pneumonia & Pleurisy w/o CC/MCC) • 247      (Percutaneous Cardiovascular Procedure w Drug-Eluting Stent w/o MCC) • 287      (Circulatory Disorders Except AMI, w Cardiac Cath w/o MCC) • 313    (Chest Pain) • 392    (Esophagitis, Gastroenteritis & Misc Digestive Disorders /o MCC) • 552    (Medical Back Problems w/o MCC) • 641      (Nutritional & Misc Metabolic Disorders w/o MCC) • 945      (Rehabilitation w CC/MCC) • 470 (Joint replacement) RAC 2012

  37. The Florida ExperienceMAC /FSCO Focused Probe, 2009 & 2010Preliminary results , FHA, RAC summit 9-10Common w/all: No Physician order for inptUpdate: 2011/moved to pre-payment for 313, 5523-12: 6 new prepayment DRGs -153, 328,357,455,473,517 RAC 2012

  38. False Claims and Kickback Lawsuits Involving Hospitals and Health Systems” –Becker’s Hospital Review, 7-11 • “Louisville, KY based Norton Healthcare agreed to pay the federal govt $782,842 in March to settle allegations that it overbilled Medicare for wound care, infusion and cancer radiation services by adding a separate E&M charge that should have been included in the basic rate. The alleged overbilling, which occurred between Jan 2005-Feb 2010 involved outpt care. The settlement is twice the amt Norton allegedly overbilled.” • ISSUE: Transmittal A-00-40, A-01-80 indicate that there is inherent nursing in all CPT codes. Therefore, the facility must ‘earn an E&M when done with a procedure.’ Unlikely events, other medical conditions being treated, new pt=examples. RAC 2012

  39. OIG’s 2011-12 Work Plan – Risk Areas for Hospitals • Outpt claims pd greater than charges. (APC methodology) • Inpt claims pd greater than chgs • Inpt $ greater $150.000 • Outpt $ greater $25,000 • One day stays at acute care • Major complications /comorb • Payments for septicemia servs • Payments for inpt same day discharges and readmissions • Outpt claims billed during the DRG payment window • Payments for hemophilia • Payments for outpt surgeries w/units greater than 1 • Inpt and outpt claims /manufacturer credits for replacement of devices • Post –acute transfers to SNF/HHA/another acute care inpt facility • SNF/HHA consolidated billing-separate outpt services • Outpt claims with 59 modifier • Inpt claims pd greater than chgs

  40. Quick Updates - Medicaid • 2-1-11 CMS Bulletin RAC for Medicaid postponed • 9-14-11 CMS issued new RAC for Medicaid final rules • Patterned after Medicare RAC – 3 yr look back, prohibits auditing done by another group, set limits on medical record requests, notify of overpayment in 60 days and coordinate. • www.ofr.gov/ORFUpload/OFRdata/2011-23695 PI.pdf • 2-16-11 CMS proposes Medicaid payment reductions for provider-preventable conditions • Follow Medicare’s hospital acquired conditions • Allow for additional conditions for reduction, state specific RAC 2012

  41. Medicaid is auditing • 1) Medicaid integrity contractors – CMS has established a 5 year look back period with 30 days to reply to requests for record (10-1-10) • 2) RAC for Medicaid – Final rule out Sept 14, 2011. To have in place by Jan 1, 2012. Target: $2.1B, with $900M to the states • 3) State Medicaid – state fraud units are auditing and coordinating all data for audits. • Concern – avoid duplication! 3 unique groups. Track and watch each one separately. • NOTE: Medicare RACs are also becoming Medicaid RACs. (HDI-Ks) RAC 2012

  42. Medicaid Hot Exposure Area • OB – protocols • Physicians/extended must order/direct pt care, pt specific. • Protocols are excellent clinical pathways, but the physician must order the protocol. • EX) Pt is 26 weeks. Nursing implements protocol for under 27 weeks. Doesn’t call the provider until results from first items on the protocol. Not billable. Must contact the provider to initiate protocol , then follow protocol. Billable. RAC 2012

  43. Protocols- Challenges with Fixes • CERT audits have continued to identify weakness in the use of Protocols. • EX) Lab urine test ordered but culture done as 2nd test due to protocol. (Noridian/Nov 2009) • EX) Without contrast but 2nd one done with contrast based on protocols. • Ensure the order is either updated or the initial order clearly states ‘with protocol as necessary.” • YEAH – how about including the protocols that are referenced in the record when submitting for audit? RAC 2012

  44. Remittance/Payment Anguish • N432 = means 2 different things on the RAs. • Pending recoupment, should coincide with the Demand letter • Actual recoupment, 41 days after the demand letter which should include interest from the 31-41st days • Remark codes from transmittal 659 clarify • N469 = CERT and MAC denials (Per MAC/NGS training on 3-11) Also used when postponing recoupment/Transmittal 141. • MAC accepted the payment (within 30 days) and did the recoupment on the 41st day too! (GA) • Transmittal 659/CR 68709 • PLB reason code (FB ) forward balance. Demand letter is also sent at this time. • PLB reason code (WO) overpayment recovery. http://cms.gov/transmittals/downloads/R6590TN.pdf RAC 2012

  45. Powerful transmittal • Transmittal 47, Interpretive Guidelines for Hospitals June 5, 2009 www.cms.hhs.gov/transmittals/downloads/R47SOMA.pdf • “All entries in the medical record must be complete. Defined by: sufficient info to identify the pt; support the dx/condition; justify the care, treatment, and services; document the course and results of care, treatment and services and promote continuity of care among providers. • “All entries must be dated, timed and authenticated, in written or electronic format, by the person responsible for providing or evaluating the service provided.” • “All entries must be legible. Orders, progress notes, nursing notes, or other entries ….. (Also CMS covers in SE1024 MedLearn release) RAC 2012

  46. More on Signature Transmittal 3278 ways CMS can meet requirements (3/10) • Provide a legible full signature (a readable first name and last name) • Provide a legible first initial and last name • Write an illegible signature over a typed or printed name. • Write an illegible signature on letterhead with information indicating the identity of the signer. (EX: a prescription has an illegible signature but the letterhead of the prescription lists three physician names. Circle the name of the physician who wrote the prescription. • Use an illegible signature accompanied by a signature log or attestation statement. • Write initials over a typed or printed name. • Write initials not over a typed or printed name, but accompanied by a signature log or attestation statement. • Neglect to sign a portion of a handwritten note, but other entries on the same page in the same handwriting are signed. • SEND the LOG WITH AUDIT MATERIAL. RAC 2012

  47. DRG High at Risk • Heart Failure (MS DRG 291, 292, 293) Physician documentation must include the ‘type ‘ of CHF in order to capture this diagnosis as either being a CC or a MCC condition. • Excisional Debridement (MS DRG 463, 464, 465) Medical record documentation must support the code assignment of 86.22 and must meet the definition of ‘excisional debridement.” …involves the surgical removal or cutting away as opposed to mechanical removal, i.e. brushing, scrubbing and/or washing. RAC 2012

  48. EMR Challenges • Hybrid records present extreme challenges in identifying the skilled care/handoffs of intensity of service between the care areas. • EMRs tend to present the patient’s history in a ‘cookie cutter’ concept without pt specific issues. • Treatment/outcomes/results of ordered services are often omitted from the clinical/nursing record. RAC 2012

  49. Living with RAC RAC 2012

  50. AHA RAC TRAC 4th Q 2010/updated 2 Q 2011 w/4Q 2011 • 1850 reporting, 1400 had activity/2000 hospitals • RAC denied $86M, up from $42 in 3rd Q • Of the $86M, 23% were appealed, 77% was not appealed/ 75% (4Q 2011) • Of the 25% that was appealed, 85% were overturned in favor of the providers. • Medically unnecessary 57% of denials, 33% were short stays • Ave automated : $399 • Ave complex : $5281 with a growing amt in medically unnecessary • Will expand the tracking of administrative burden RAC 2012

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