II. Definitions
- Recovery Audit Contractor (RAC)
- Private auditors contracted by government to recover "over-billing" dollars
- Auditors receive incentives for recovery and awarded higher bounty for greater recovery
- Review is often based on software mining and assign error rates based on certain number of charts (e.g. 100)
- Error rate is then extrapolated over prior years and revenue loss for facilities can be substantial based on small reviews
III. Background: Four contractor regions in U.S.
- Health Data Insights (West)
- CGI (Midwest)
- Diversified Collection Services (Northeast)
- Connolly Consulting Inc (South)
IV. Pitfalls: Avoid boiler-plate, cloned exams
- History
- Document 4 HPI components with case specific detail
- Note review of PMH, Family History and social history
- Review and summarize old records
- ROS should include 2-3 pertinent positives and negatives
- Exam
- Do not over-document exam
- Review nursing data and note this
- Assessment
- List the contributing co-morbidity and complexity
- Document high risk diagnoses (e.g. Altered Level of Consciousness)
- Document response to treatment and reviewed results (play-by-play)
- Document independent interpretation of results
- Document discussion with other providers
- Document summary of findings
- Document differential diagnosis
- Document Critical Care
- Do not minimize
- Explain clearly the system/organ that is in failure
- Contrast with a level 5 visit where there is a risk of organ failure
- Explain the critical interventions
- Document Critical Care minutes (80% are <74 minutes)
V. References
- Granovsky (2012) MN ACEP Reimbursement and Coding Conference, Minneapolis
- Johnson (2012) MN ACEP Reimbursement and Coding Conference, Minneapolis