3 Coding Problems RACs Often Identify
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1. Short stays and one-day stays. Short stays and one-day stays are an easy target for RAC medical necessity reviews because of complex rules on the difference between an inpatient stay and a one-day stay. For example, a patient comes to the ED with chest pain and is admitted and sent to the catheterization lab, where tests are negative, and is released the next morning with no symptoms. If the patient is billed as a full admission, the entire hospital bill can be at risk of recoupment, although in some cases the hospital can rebill for some Part B services.
"Getting the patients' bed status right from the start will save a lot of money," Ms. Lamkin says. A bed status error can be avoided from the get-go by properly screening on admission. The hospital must have systems in place to stay current on the rules and to screen admissions for intensity and severity. The care management team should develop a collaborative relationship with the medical staff. "Physicians need to understand admission criteria and write the appropriate order," she says.
If the short-stay patient was mistakenly admitted as an inpatient, the hospital can still change the status before discharge and billing by applying condition code 44. However, obtaining the code takes up physician time because only the UR committee and another physician can make the change. Also, the patient must be notified because the change may require additional patient responsibility on the bill. In the longer term, a hospital can track condition code 44 usage to determine if there is a trend in improperly identifying bed status.
2. Billing for infusion therapy and IV therapy. Outpatient hospital infusion therapy is another vulnerable area for facilities and thus is a RAC target. Documentation and billing can be confusing and difficult for staff because of the rules around documentation, coding and modifiers. RACs use automated searches to look for "medically unlikely edits" that tend to be documentation or clerical errors, such as the same code billed multiple times for a procedure like hydration therapy, which can only be billed once per patient per date of service.
Here are some other pointers on IV hydration:
* IV hydration can only be billed before or after a therapeutic infusion and cannot be billed with a blood transfusion code.
* Another area of scrutiny on IV hydration includes units billed and coded – 96360 in the first hour of service and then 96361 for each additional hour.
* Start and stop times must be included in the clinical documentation for each bag as well as route of administration. Mistakes also include a stop time documented before the start time because "p.m." was charted instead of "a.m."
* Another common mistake is entering the dosage in milligrams and billing for each milligram instead of billing in six-milligram units. This could be a chargemaster issue leading to a pattern of incorrect billing that appears to be disregarding the rules.
* Any physician documentation for billing must match the hospital documentation and billing. Otherwise, both could be at risk.
3. Incorrect discharge status. RACs are taking a close look at discharge status in relation to the post-acute care transfer rules, which involves paying hospitals less than the full DRG when patients are discharged to certain post-acute settings rather than to their homes.
Here are some pointers on discharge status:
* If a patient is coded 01 to go home but is discharged to a skilled nursing facility as code 03 or inpatient rehabilitation as code 65, the hospital could be at risk of a RAC take-back of the DRG and payment on a per diem basis.
* Another trigger for RACs is a transfer to a skilled nursing facility without a three-day stay in the acute-care hospital. RACs could easily pinpoint this issue in an automated review.
* If the patient is coded 01 and then saw a physician who sent the patient to another setting such as a skilled nursing facility, care management or the physician advisor should provide documentation for discharge planning to support code 01, showing it was not a transfer.
* If the skilled nursing facility admission occurs within three days of discharge, the hospital is also at risk. To address this potential problem, some hospitals hold bills for three days to check on patient status before sending them out.
* The only way to ensure accurate coding is to track patients after discharge. Before coding the discharge, hospital staff should inquire with the post-acute facility about patient placement. RACs can easily identify this issue through automated review.
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