By Karen Bowden, RHIA, Executive VP Revenue Integrity Operations
Electronic Medical Records and RAC Complex Reviews
Like many hospitals, it would not be unusual to find that your facility’s inpatient admission records are housed in multiple places including a decentralized paper record, the EMR, and/or that portions may even be dispersed across two or more electronic storage systems. Now more than ever, medical records are in a hybrid state as healthcare entities move towards a true electronic medical record (EMR).
While the decentralization of medical records poses its own unique problems to your hospital, the national roll-out of Medicare’s Recovery Audit Contractor (RAC) program can make the transition to EMR even more painful.
When a RAC audit of your hospital is underway, the Medicare RAC will perform two types of reviews to find improper Medicare payments to your facility—automated reviews and complex reviews. Automated reviews are done by processing your past Medicare claims through the contractor’s proprietary adjudication systems, and are meant to find clear-cut cases of improper payments (i.e., a duplicate surgical procedure billed twice and paid twice). In contrast, complex reviews are much more in the grey area. The RAC thinks that a claim probably had errors, but they need your medical records to make a determination. The RAC sends a request letter and you have 45 days to send the medical records.
With your medical record information in disparate locations, getting a complete medical record out the door within 45 days of the request letter becomes a challenge. One missing record has the potential to cause millions in unnecessary denials and lengthy appeals.
100% Complete Medical Records
In order to assure a complete record is submitted to RAC or any other audit agency, Craneware InSight Consulting recommends that each facility with a hybrid medical record system document a full inventory of where all records are stored. With a master inventory, your RAC team can find and assemble all portions of the record and meet RAC request deadlines. The following is an example of one such scenario:
Hospital A has a growing inventory of electronically stored documents in its HIS system. The HIS system also links access to reports stored in proprietary vended systems, such as the Cardiac Cath Lab, while other portions of the record are still maintained on paper. When a record request is received for a RAC complex review for a patient who had a procedure in the Cardiac Cath Lab, the record components must be assembled from paper records, the HIS EMR as well as from the Cardiac Cath Lab in order to submit a complete record.
Additionally, Craneware InSight Consulting recommends that a check-off sheet be prepared for each type of record that may be requested. Check sheets will assist that staff has the key components of the record that tell the story of services provided and billed in every medical record submission. Policies should be developed to consider whether or not outside records such as those from transferring Emergency Departments, nursing homes and/or other records will be included.
A few examples of specialized checklists that should be developed for complex chart requests include:
- DRGs where a single CC/MCC is present.
- DRGs that group based on coded ventilator services.
- Procedure based DRGs.
In addition to basic key components of the medical record that always include H&P, discharge summary, ED records (if applicable), progress notes, consultations (if applicable), physician orders (especially the admission order), lab, radiology, all diagnostic and therapeutic services, nursing notes, assessments, vital signs, I&O, medication administration records, etc. the following items should be added to checklists to assure complete submission prior to sending records to the RAC:
- DRGs with a single CC/MCC – in addition to basic key components of an inpatient medical record, staff preparing records should print the coding sheet to identify the diagnosis that qualified as the CC/MCC. Staff should assure the documentation that supports the CC/MCC is present prior to sending records.
- DRGs with Vents – staff should assure all ventilator flow sheets from the time the patient was placed on a ventilator until it was removed, should be present in the chart prior to sending records to the RAC.
- DRGs impacted by the disposition status – staff should assure notes related to the patient disposition such as transfers to an acute care facility/SNF and/or that the patient expired are complete.
- Procedure based DRGs – staff must assure that operative reports and consent forms are included in record submissions.
Final Steps to Avoid Sending Incomplete Documentation to RAC
Craneware InSight Consulting also recommends that services rolled into inpatient bill due to 72 hour rule must be reviewed prior to record submission. An itemized bill should be utilized to review all services, especially ambulatory surgery services that may be coded and charged on the inpatient bill. If outpatient services are billed with the inpatient admission, the medical records for those services must be included in the report submission to support coding and billing.
If key components of a record are missing, policies must be written to define who will follow-up on finding the records and if an extension will be requested.
Taking the time to assure records are complete and in good order which includes assuring the sections of the chart are in date order for easy reading when records are submitted will prevent unnecessary denials and risk of revenue loss because of incomplete documentation.
Feel free to use or distribute the sample complete record verification form, or use it as a template to create your own. Different RAC contractors may request different records, so use your first RAC record request letters to create your own verification form.