CMS Releases List of RAC Audit Vulnerabilities
Common inpatient mistakes that often lead to claim denial In general, claims were denied because the documentation provided did not contain sufficient information to support the diagnosis, justify the treatment/procedures, document the course of care, identify treatment/diagnostic test results and promote continuity of care between health care providers. The cause of most denials was that submitted documentation did not necessitate an inpatient level of care, and care could have been provided in a less intensive setting, a Recovery Audit Contractor’s (RAC’s) report found. When admitting patients to an inpatient setting, providers need to consider several things. First, the severity of the signs and symptoms of the patient needs to be considered and documented. Also, the medical probability of adverse complications occurring should be noted. The need and availability for diagnostic studies and procedures also must be taken into account. If the patient’s medical condition, safety or health would not be threatened by providing services in a less intensive setting, then inpatient admission is not justified. The Centers for Medicare and Medicaid Services (CMS) reminds providers that all documentation must be legible. If a certain field is not applicable, “N/A” should be written. The field should not be left blank. Additionally, RAC reviewers found that certain records were not consistent. If an entry is submitted that contradicts a previous submission (due to error or otherwise) then the reason for the contradiction should be noted. Any changes in the patient’s condition or course of care should be noted, as this directly effects the reviewer’s determination. (Cont. DRG CODES Page 2)