Using checklists of discharge criteria, RAC auditors look for documented evidence of the severity of the patient’s illness and the intensity of services required by the patient, Dr. Lipsitz wrote in her blog.
“If they can’t identify this information, written legibly and in understandable terms, they are likely to determine that the patient could have received further treatment at a lower level of care,” she added. “Thus they may contest payment for the last few days of care.”
For example, if the patient is kept in the hospital for observation, the physician needs to write more than, “Observe over weekend.” The note needs to be quite specific, Dr. Lipsitz wrote.
The following model entry would be likely to survive a RAC audit: “Assessment and Plan: Postoperative fever: possible sources of fever include wound infection, sepsis, urinary tract infection, or pneumonia. Get chest x-ray, blood cultures x 2, urine culture. Will consult Infectious Diseases for advice on further management. Reassess the patient in 24 hours and consider wound culture. Increase IV fluid rate to 125cc/hr.”
Dr. Lipsitz identified seven simple rules to improve physicians’ documentation and reduce denials.
1. Also write for the auditors. Don’t just write for other physicians; write for utilization reviewers, coders and auditors, as well. “The days of utilizing the medical record to communicate only with other caregivers are over,” Dr.
Lipsitz said.
2. Show what makes the patient so sick. Document severity of illness and intensity of services that justify a longer stay. What services can be given only at this level of care?
3. Treat weekends just like weekdays. Weekend stays are just as costly as weekday stays. Reassess patients for potential discharge on an ongoing, daily basis.
4. State why your plan is appropriate. “Remember the key word ‘because,’ even if you don’t specifically write it,” Dr.
Lipsitz said. For example: “The patient needs acute inpatient care because the source of her fever is unclear and needs further evaluation with multiple studies and consultations.”
5. Show details supporting your decision. Medical decision-making is complex, so write down all the facts that go into your plan.
6. Don’t copy and paste boilerplate statements. “Repeatedly using the same justification for continued LOS weakens your arguments,” Dr. Lipsitz wrote.
7. Begin discharge planning ASAP. Delays in discharge planning cannot be used to explain a longer stay.
Read Dr. Lipsitz’s blog.
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