It's all too easy for coders to make mistakes that can be picked up by recovery audit contractors, says Gloryanne Bryant, regional managing director of health information management and co-chair of the RAC Committee for Kaiser Northern California.
"The volume of claims and coding for Medicare alone is just unbelievable," she says. Medicare regulations are three times as long as the U.S. tax code. "With this sort of complexity, coders are set up for errors." Unlike private payors, Medicare does not require preauthorization, so hospitals can be committing mistaking without knowing it, she adds.
She names three areas where mistakes are common:
- Some MS-DRGs are with and without MCC/CC. Coders have to pay attention to differences between major complications and comorbidities (MCCs) and complications and comorbidities (CCs).
- Distinguishing between DRGs. For example, there are several DRGs for chest pain. Be careful to use the right one.
- Outpatient codes. In the hospital outpatient setting we are seeing more automated data mining reviews, including units of service, accuracy of CPT and E&M codes as well as injection and infusion documentation.
Consider a compliance program
Hospitals that want to avoid errors should consider implementing a compliance program, performing regular audits. "A compliance program is not mandated but it behooves you to have one," Ms. Bryant says. "It's like a certificate of inspection that you see on a new article of clothing." The audits can be focused, looking at a certain DRG, or they can be random, you using an algorithm. In an audit, a small hospital might look at 100-200 claims, while a larger organization might look at a thousand.
The audit can be done by in-house personnel, which is how Kaiser does it, or it can be outsourced, which is what a smaller hospitals probably would do. Ms. Bryant oversees a staff of seven full-time auditors for her 21-hospital Kaiser region. "An outside audit can affirm that internal processes are working," she says. She recommends that small hospitals conduct routine audits, perhaps twice a year, and then follow up with smaller audits focusing on patterns that have been uncovered.
Audits should also cover issues that RACs post on their websites. Staff should frequently consult the RAC website because issues can come and go. "The RAC website can be very confusing," Ms. Bryant says. "The RAC may pull issues off its website and later they may pop up again. We aren't told why." Even if the issue is no longer on the website, the hospital should perform an audit on it, anyway.
Learn more about Kaiser Northern California.
Related articles on guarding against RACs:
6 Points on Avoiding RAC Take-Backs for Incorrect Patient Status
Can RACs Review a Claim More Than Once?
New Semi-Automated Reviews Help RACs Extend Their Reach