As the Centers for Medicare & Medicaid Services (CMS) continues its limited Recovery Auditor (RAC) restart, it’s important to pay attention to what areas are being targeted for audits by existing contractors.

The RAC program had been on hold due to the re-contracting and reassigning of regions. In addition, there was a lawsuit pending between CMS and CGI over RAC reimbursement rates, models, and approaches. The lawsuit was resolved in favor of CMS last summer. But CGI immediately appealed, causing further delays and the postponement of a full restart of the RAC program.

At this point, we are waiting for the CGI case to be both filed and heard again. But in the meantime, CMS has allowed current contractors to begin re-auditing. Here are a few points to consider during the RAC limited restart.

Be Aware of What the Auditors Are Looking For

From a software perspective, the inevitable full return of RACs looms like a bad omen. One way for coders to cope is to research the top audit-targeted, diagnosis-related groups (DRGs) before the RACs ramp back up to full speed. 

Why? Because almost all current reviews are now going back to DRGs. 

Some top DRGs being audited include: 

  • 193-SIMPLE PNEUMONIA & PLEURISY W MCC
  • 392-ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC
  • 683-RENAL FAILURE W CC
  • 177-RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC
  • 640-NUTRITIONAL & MISC METABOLIC DISORDERS W MCC
  • 682-RENAL FAILURE W MCC
  • 871-SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC
  • 065-INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC
  • 377-G.I. HEMORRHAGE W MCC
  • 917-POISONING & TOXIC EFFECTS OF DRUGS W MCC
  • 309-CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC
  • 191-CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC
  • 292-HEART FAILURE & SHOCK W CC

Tips on Reviewing

According to Kim Scheel, CEO of KDS Coding LLC in Pacific, Mo., one of the most prevalent reasons for denial is failure to support secondary diagnoses. This is often due to coding from documentation without supporting clinical evidence, which is preventable with proper prior planning.

Here’s an example: consider a scenario in which “postoperative respiratory failure” is indicated by the physician in the progress note. However, clinical evidence does not substantiate this, since there was no logged difficulty in breathing, O2 stats were normal, and there was no laboratory work for ABGs. In this case, the best option is to query the physician. 

Here’s another example of a common yet preventable occurrence: secondary diagnoses codes that were not treated during the current admission. Past medical history diagnoses are not codeable unless they affect the current treatment or meet the secondary diagnoses criteria (as above).

If a valid secondary diagnosis code was treated, monitored, and evaluated during this admission, however, and it is not on the discharge summary, this marks another high-risk area for denial. If the secondary diagnosis code is significant, it needs to be summarized on the discharge summary.

Now is the Time

Because the industry remains in a limited RAC restart mode, at least for now, audit volumes haven’t been high. Moreover, we’re still on hold as far as new contractor assignments and announcements. And finally, again, we’re still waiting for CGI’s appeal to be heard in its case against CMS. 

All of these components dovetail nicely to contribute to the brief respite we’re enjoying before the RACs return with a vengeance.

This makes now the perfect time to ensure that you and your team are up-to-date, know what to expect, and have the proper systems in place. Ideally, this process should include a lean, prepared, and centralized audit management department.

About the Author

Dawn Crump, MA, SSBB, CHC, has been in the healthcare compliance industry for more than 18 years and joined HealthPort in 2013 as vice president of audit management solutions. Prior to joining HealthPort, Crump was the network director of compliance for SSM. She has healthcare experience in education, organization development, quality improvement, and corporate compliance. She is a former board director of the Greater St. Louis Healthcare Finance Management Association chapter and currently serves as the networking chair. Crump is also a member of the Health Care Compliance Association (HCCA).

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