Guest Post: Reduce RAC Vulnerabilities with a Quality CDI Program

DRG (diagnosis-related groups) validation issues have been the main target of RAC (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 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.”

Through the years, however, some have suggested that CDI specialists submit too many “leading questions” in their query forms and requests which may sway the physician’s decision one way or the other, according to Spryszak. The definition of “leading” has been the subject of much dispute. As a result, the American Health Information Management Association (AHIMA) published it Guidance for Clinical Documentation Programs to help outline what would constitute a “leading query” versus a compliant query.

Spryszak refers back to the example of sepsis vs. urosepsis to provide an example of the physician query’s impact on both the CDI program and facilities’ vulnerability to RACS.

“If a higher than normal percentage of patients in a facility are being coded to sepsis instead of just a urinary tract infection, it may be because the processes involved,” she says. “A review of these cases may show that the final DRG assignments were the result of asking leading questions.”

When it comes to RAC audits and denials, every part of the process matters; but when you have a thorough, compliance-based CDI program in place, it puts a facility in that much better of a position to defend against them.

Editor’s Note: This article was written by James Carroll, for HealthLeaders Media, sister publication to the ACDIS, on June 17, 2010. Read more about what individual CDI specialists are experiencing in terms of RAC reviews and RAC requests for physician query documentation in the July edition of the CDI Journal.