Pre-Bill Auditing: The Next ICD-10 Hot Button Issue. Presentation Objectives

Transcription

1 Pre-Bill Auditing: The Next ICD-10 Hot Button Issue Featuring Kimberly J. Carr RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10 CM/PCS Trainer Jonathan LaFleur, BSN, RN, CCS 1 Presentation Objectives Define at risk claims Understand circumstances that necessitate a pre-bill audit Learn the standard process for a pre-bill audit Discover how pre-bill audits can fuel coder, CDI, and physician education Identify the possible outcomes of a pre-bill audit 2 1

2 Retrospective vs. Pre-Bill Auditing Retrospective Audit Claim has already been billed Discharge date is weeks/month past Error in practice has been repeated If rebilled, there is a cost If rebilled, there is a revenue delay Concurrent education opportunity missed Missed Core Measure/Quality documentation Pre-Bill Audit Claim is still in-house Discharge date is hours/days ago Opportunity to prevent repeated errors Reduce likelihood of rebills Avoid revenue delays Great opportunity for on-the-go education Promote Core Measure/Quality documentation 3 Why Perform Pre-Bill Audits? Help generate solutions to: Improve documentation Increase compliance Reduce days in revenue outstanding Identify both overcharges and undercharges Recover any net amounts due to the hospital, thus increasing income 4 2

3 Why Perform Pre-Bill Audits? Ensure a "clean bill" the first time Reducing red flags such as: Third party audits Patient requests for audits Allows for timely correction of charge errors by the source department Pinpoint root cause of documentation and billing errors to allow corrective action 5 Pre-Bill Audit Focus Inpatient setting: Ensure claims have the correctly assigned: MS-DRG code Complication codes Outpatient setting: Focus on medical necessity 6 3

4 Planning for Pre-Bill Audits Focused pre-bill Inpatient audits should include: MS-DRGs Present-on-admission (POA) status indicator Severity of illness Risk of mortality Clinical indicators Discharge disposition 7 Planning for Pre-Bill Audits Focused pre-bill Outpatient audits should include: APC assignment E/M assignment Compliance issues review Updated coding changes and regulatory guidance Medical necessity 8 4

5 Planning for Pre-Bill Audits Ensures documentation supports the coded and billed service Identifies when a record is improperly coded and billed Identification of improperly coded and billed services is imperative Organizations required to comply with the 60-day repayment window 9 Poll # 1 Does your organization use pre-bill audits? 10 5

6 Defining At Risk Claims High Dollar Claims What does your organization consider high dollar? Is the claim high dollar because of a DRG error? Are high dollar claims inherently red flags for third-party audits? The bigger they are the harder they fall 11 Defining At Risk Claims No CC/MCC How much does a missed CC/MCC really cost? How much does a second set of eyes cost? Correlate with length of stay and DRG to identify target DRGs for your facility Aim for a focused, laser-lined audit. 12 6

7 Defining At Risk Claims Single CC/MCC How solid is the solitary CC/MCC? How much time and revenue will be lost if that CC/MCC is denied?? Which DRGs are currently being targeted by third-party auditors? 13 Defining At Risk Claims Long stay, low-weighted DRG Why was the stay so long? Is it possible that co-morbid conditions can extend a stay without being a CC or MCC? Are there clinical indicators for diagnoses that are never documented, never well-documented, or never consistently documented? 14 7

8 Defining At Risk Claims Short stay, high-weighted DRG What happened? Are the CCs and/or MCCs clearly supported? Was this a transfer? Was this a mortality? 15 Defining At Risk Claims CDI/Coding Mismatch Why do CDI and Coding disagree on the DRG? Is this a Coding Clinic / Guideline issue? Is this a clinical indicator issue? Did CDI miss a concurrent query opportunity that Coding turned into a retro query opportunity? Is this an opportunity for CDI education? 16 8

9 Defining At Risk Claims Mortality Is there a CC/MCC? If not, why not? What is the severity of illness? If not 4, why not? What is the risk of mortality? If not 4, why not? Is the record even complete? 17 Defining At Risk Claims Red Flags for third-party audits What is currently on their radar? ABLA? AKI? ATN? Encephalopathy? Acute Respiratory Failure? What has their justification for denial been? Are the clinical indicators missing? Is the documentation poor? 18 9

10 Defining At Risk Claims OIG/RAC hit list MS-DRG assignments that require mechanical ventilation Outpatient dental claims Right heart catheterizations and Endomyocardial biopsies billed during the same operative sessions Kwashiorkor Bone marrow or Stem cell transplants 19 Defining At Risk Claims Core Measures/Quality/HACs/PPCs/PSIs Is the POA flag N? Falls Intraoperative/postoperative complications Pressure ulcers CAUTI CLABSI Nosocomial infection Poor glycemic control VAP 20 10

11 Defining At Risk Claims Fall out Pepper Report cases Stroke Intracranial Hemorrhage DRGs 061, 062, 063, 064, 065 and 066 and DRGs 067, 068 and 069 should be reviewed for over-coding or undercoding Unrelated OR Procedure All unrelated OR Procedure DRGs should be reviewed to determine if the principal diagnosis is correct Surgical DRGs with CC or MCC Surgical DRGs should be reviewed for over-coding or under-coding of CCs or MCCs 21 Outcomes of a Pre-Bill Audit Ensure accurate and precise coding Fortify claims against denials Eliminate Re-Bills Decrease A/R days 22 11

12 COPD vs. ARF Case Study A 59 y/o female is admitted with a COPD exacerbation and the provider documents hypercapnic respiratory failure at the bottom of the H&P which is captured with ICD-10-CM code J96.22 (Acute and chronic respiratory failure with hypercapnia) There is no documented respiratory distress or labored breathing Respiratory rate is 19 SpO2 is 93-96% on 3Lpm via nasal cannula, which is the patient s home O2 delivery ABG shows a ph of 7.38 ( ), PaO2 of 67mmHG (80-100mmHg), and a PaCO2 of 77mmHg (35-45mmHg) 23 COPD vs. ARF Case Study A diagnosis of acute respiratory failure must not be assigned exclusively based on lab values, however, but also by the degree of change from the patient s expected, baseline values. Question: Is there a deviation from baseline? Answer: No, it was determined that there was insufficient clinical evidence in the records available to substantiate a diagnosis of acute respiratory failure and that this record should be coded with J44.1 (COPD with acute exacerbation) as the principal diagnosis

13 Code Comparison Billed MS-DRG 189 R.W GLOS 3.9 PAYMENT: $5,588 Third Party Recommendation MS-DRG 191 R.W GLOS 3.3 PAYMENT: $4,201 PDX: J96.22, Acute and chronic respiratory failure with hypercapnia SDX: J44.1, Chronic obstructive pulmonary disease with exacerbation PDX: J44.1, Chronic obstructive pulmonary disease with exacerbation SDX: J96.12, Chronic respiratory failure with hypercapnia Note: The hospital was asked to pay back $1, AV Block with AKI Case Study A 40 year old is admitted to the hospital with a diagnosis of 3rd degree AV block (I44.2). The provider also assigns a diagnosis of AKI (N17.9) as a secondary diagnosis. The patient s serum creatinine ranged between mg/dL with documentation that creatinine fell to 2.5 with gentle hydration, which is around baseline. GFR was measured to be between during the hospitalization The is no documented decrease in urine output The patient carried a diagnosis of chronic kidney disease, stage III

14 AV Block with AKI Case Study KDIGO Criteria1 for AKI: Increase in serum creatinine greater than or equal to 0.3mg/dL within 48 hours Increase in serum creatinine greater than or equal to 1.5x of baseline within the previous 7 days Decrease in urine output below 0.5mL/kg/hr for 6 1 Kidney Disease: Improving Global Outcomes International Society of Nephrology (2012). KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International, 2(1), Code Comparison Billed MS-DRG 309 R.W GLOS 2.6 PAYMENT: $3,577 PDX: I44.2, Atrioventricular block, Complete SDX: N17.9, Acute kidney failure, unspecified (CC) Third Party Recommendation MS-DRG 310 R.W GLOS 2.0 PAYMENT: $2,555 PDX: I44.2, Atrioventricular block, complete SDX: N18.3, Chronic Kidney Disease, stage 3 SDX: N18.3, Chronic Kidney Disease, stage 3 Note: The hospital was asked to pay back $1,

15 Single CC Case Study An otherwise 72 year old is admitted for a small bowel obstruction. Due to some questionable findings on imaging, the surgeons elect to perform an ex-lap. On admission the patient s sodium was 132 and the admitting physician documents hyponatremia On POD #1 the surgeon documents anemia: expected 29 Pre-Audit Coding With nothing else remarkable in the chart the coder assigns the following: Pre-audit chart MS-DRG 357 R.W GLOS 5.1 PAYMENT: $9,477 PDX: K56.60, Unspecified intestinal obstruction SDX: E87.1, Hyponatremia (CC) SDX: D64.9, Anemia unspecified PPX: ODJDOZZ, Inspection of Lower Intestinal Tract, Open Approach 30 15

16 Single CC Case Study Since this claim only has one CC it is flagged for a pre-bill audit. The auditor identifies a few clinical indicators within the chart: The patient s hemoglobin on arrival was 14.2 and postoperatively it was 9.6 The patient received 2 units of PRBCs Prior to discharge the hemoglobin was re-measured and was 12.1 Auditor recommends to coder that query be placed to identify the type/etiology of anemia and acuity. Within 48 hours of discharge a query placed and response of blood loss anemia, acute, not a complication of the surgery returned. The claim is sent out with the following: 31 Code Comparison Pre-audit chart MS-DRG 357 R.W GLOS 5.1 PAYMENT: $9,477 PDX: K56.60, Unspecified intestinal obstruction SDX: E87.1, Hyponatremia (CC) SDX: D64.9, Anemia unspecified PPX: ODJDOZZ, Inspection of Lower Intestinal Tract, Open Approach Post Pre-Bill Audit MS-DRG 357 R.W GLOS 5.1 PAYMENT: $9,477 PDX: K56.60, Unspecified intestinal obstruction SDX: E87.1, Hyponatremia (CC) SDX: D62, Acute posthemorrhagic anemia (CC) PPX: ODJDOZZ, Inspection of Lower Intestinal Tract, Open Approach SPX: 30253N1, Transfusion of Nonautologous Red Blood Cells into Peripheral Artery, Percutaneous Approach 32 16

17 Poll # 2 In what focus areas does your organization use pre-bill audits? 33 Performing a Pre-Bill Audit 1. Identify charts that need a pre-bill audit 2. Place the bill on hold 3. Place the chart in the audit queue 4. Conduct the Audit 5. Did the Auditor agree or disagree with the DRG assignment? If Auditor agrees, send the record to billing If Auditor disagrees, initiate dialogue 34 17

18 Pre-Bill Audit Process Each assigned code should be compared, contrasted, and analyzed to: 1. Confirm presence of clinical documentation as expected 2. Assess quality and content of the clinical documentation to support the assigned codes 3. Evaluate assigned codes vs. the application of final codes based on a coding professional s manual review of the clinical documentation 35 Pre-Bill Audit Process Dialogue: Who needs to be involved in the conversation? What if Coding disagrees with the audit findings? If a query is indicated who generates the query? Who makes the changes to and finalizes the chart? If this is a physician education opportunity, who initiates? Who owns the education process? 36 18

19 Extending the Value of Pre-Bill Auditing Four areas for extended value: Coder Education Physician Education CDI Education Organization wide 37 Value to Coders Provide timely one-on-one educational feedback to the individual coder daily Address missed codes despite supporting documentation being present within the medical record Improves coding accuracy Provides immediate feedback on coding quality Provide clarification on Official Coding Guidelines/Coding Conventions not being fully understood 38 19

20 Value to Physicians Provide immediate feedback to physicians to address: Insufficient clinical documentation Insufficient or inconsistent documentation to support code assignment Lack of supporting documentation 39 Value to CDI Specialists Provide one-on-one feedback to the CDIS Provide timely feedback on query process/templates that need to be developed or revised Pinpoint certain MS-DRG for potential revenue and reimbursement losses Identify problem areas in existing clinical documentation by physician and/or specialties Reinforce and/or re-educate CDIS in regard to revenue cycle and reimbursement tenets 40 20

21 Value to the Organization On-going identification of: Comprehensive data to demonstrate the financial consequences of incomplete documentation to physicians reluctant to change Payment issues Why are denials occurring? Can denials be identified by code or provider? What measures can be adopted to address denials? Can coders be educated? 41 Value to the Organization Feedback, Feedback, Feedback Data is good, but information is better Sharing findings on a regular basis engages participants Need for How did I do? Share the good, the bad and the ugly! Set expectation for receiving results Understand how all the data elements fit together and impact various initiatives 42 21

22 Bottom Line Your organization is exposed to potential risk without a solid pre-bill auditing program in place QUESTION: Can your organization afford not to be right the first time? 43 Conclusion Incorporating a pre-bill audit process ensures timely: Documentation to support coded and billed services Reduction in your organization s regulatory exposure Securing appropriate reimbursement for your facility Now is the time to initiate! 44 22

23 QUESTIONS? 45 Contacts Kimberly Carr RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer Jonathan LaFleur BSN, RN, CCS Reisterstown Road Baltimore, MD Phone: