Guest Post: WWRD: What would the RAC do?

by Karen Newhouser

There has been much discussion based on what Recovery Audit Contractors (RAC) and other state and federal regulatory bodies are doing or what their next move will be (though does anybody really know?!?).

We’ve all heard the stories of denials of well documented and clinically substantiated conditions; of the role the RAC reviewer incentive structure plays in RAC determinations, of confusing correspondence addresses, etc. Whether or not the stories are true doesn’t matter as much as the attention such stories garner. We’ve also heard of the fear that prevails and this makes me wonder about the effect of these reviews on our day-to-day workflow.

I recommend we stop, take a deep breath, and think…Why not switch our focus from “what would the RAC do” back to what care was provided and how was it documented in the medical record?

Now, I’m not saying we should ignore RAC, or forget that they are there. Believe it or not, they do keep us grounded. I’m just saying let’s try not to make them the focus.  Let’s try not to work according to the WWRD principle.

We are currently in the midst of a nationwide movement toward quality and public reporting. It is commendable that our national focus has turned to the quality of healthcare. And providing quality care is all about doing the right thing at the right time. If we stay true to who is at the center of this movement, ‘the patient,’ and set the stage for the right process to ensure that we do the right thing at the right time, good outcomes will prevail.

Let us take that thought and apply it to the world of CDI.  The concurrent process of CDI, in and of itself, takes place at the ‘right time,’ while the patient is still in the hospital and we have all the necessary medical record, laboratory, and dietary information available to us. Through our consistent, thorough review of the information contained within the record we can help clarify ambiguous information, identify potentially omitted diagnoses, and ensure the record accurately captures all the clinically relevant care provided.

Although our task can be complicated, we have  available to us several documents that assist us in our endeavors to do the ‘right thing:’ ACDIS’ Code of Ethics, AHIMA’s 2008 practice brief, Managing an Effective Query Process, the 2010 document, Guidance for Clinical Documentation Improvement Programs, and their 2010 publication, Clinical Documentation Improvement Toolkit.  In order for our day-to-day CDI practices to be able to withstand audit scrutiny we must use these guidances, plus our own facility-specific policies and procedures to guide us.

When we stray from our ethical and moral core, and away from the guidelines in place to protect us, we could find ourselves alone and exposed. There have been several discussions (most recently during the November 17, 2011 ACDIS Quarterly Membership Conference Call) regarding the dangers of leading queries and the potential legal implications involved. We all need to operate within the guidelines and be prepared to stand up and defend the information contained within the medical record.

If we center our attention on doing the ‘right’ thing, focus on our responsibility to the patient, and continue to assist in the precise and complete representation of the patient encounter within the medical record, we will have done our job, and possibly kept the RAC at bay. Let us do what we do best, according to the guidelines, and let the policies and procedures that are in place steer us on the right path.

Don’t think about what RAC would do; think about doing the right thing at the right time for the patient.

Editor’s Note: Karen Newhouser, RN, BSN, CCM, CCDS, at the time of this article's release, was a CDI specialist at Miami Valley Hospital in Dayton, OH. Her background in critical care nursing and case management gave her the solid foundation to be successful with CDI since 2004. She finds great rewards in sharing her expertise and imparting her knowledge through teaching.