Reduce RAC Vulnerabilities with a Quality CDI Program

James Carroll, June 17, 2010

DRG (diagnosis-related groups) validation issues have been the main target of RACs (recovery audit coordinators) nationwide in recent months. When unclear documentation results in improperly assigned DRGs, it puts facilities at risk for RAC denials. However, an effective clinical documentation improvement (CDI) program aims to minimize these financial risks by producing the most accurate and comprehensive medical records possible—records that fully support the condition of the patient and the services rendered.

A CDI specialist is trained to identify terms and phrases that a physician uses that may lead to the assignment of imprecise or non-specific codes, according to Lynne Spryszak, RN, CCDS, CPC-A, CDI Education Director for HCPro, Inc.

"The CDI specialist serves as a translator between the physicians and their clinical language, and the coders and ICD-9 coding language, which are not always synonymous," says Spryszak.

For example, a physician might use the term "respiratory insufficiency" while talking about someone who is on a mechanical ventilator. In his mind, he is thinking of a patient who has respiratory failure and needs medical support, but in the coding world, the term "respiratory insufficiency" has its own unique ICD-9 code, which, when measured on a severity of illness and risk of mortality scale, is comparatively low, according to Spryszak.

CDI involvement in RACs
The CDI program's connection to the RAC process runs deep. When the documentation in the record does not match the services administered, the provider may see a RAC denial that could have been prevented with a sound CDI program. Spryszak offers the diagnosis of urosepsis as an example.

"While going through medical school students learn that urosepsis is an overwhelming infection that started in the patient's urinary system, which indicates a very sick patient," says Spryszak. "However, in the coding world, the term urosepsis equates to a simple urinary tract infection."

Enter the RAC, who, when reviewing a case which grouped to MS-DRG 872—Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours without MCC—notices that the patient had a short stay and received only one antibiotic. When reviewing from a retrospective audit point of view, this would be a likely indication that the resources given to the patient were typical of treating a urinary tract infection, as opposed to the higher severity sepsis case which coincidentally carries a higher paying reimbursement. A RAC would evaluate this and likely perceive it as an invalid DRG assignment and thus deny it, according to Spryszak.

"A good quality documentation improvement program that focuses on not only supporting the DRG assignment but also focuses on clarifying all conditions that are imprecise will better support the record from a compliance standpoint," she says. "If you have a complete, precise medical record, it should be able to stand up to audit."

James Carroll James Carroll is associate editor for the HCPro Revenue Cycle Institute.
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