In terms of volume, a facility will receive only eight complex
medical record requests in a 365-day period (excluding test
claims); however, when a medical record request is received
there is much work to do before retrieving the medical record.
First organizations should validate the list for inclusion in the
list of approved issues posted by the RAC. This includes confirming the stated reason for review and the issue posting date.
It is important that RACs request the correct issue and organizations send the appropriate request.
If there is a problem, organizations should contact the RAC.
Phone calls are acceptable for communication, but e-mail is the
best format to provide a record of the exchange. Organizations
should follow-up if they have not received a response within 48
All contractors do not share a posting date so it’s necessary to
maintain an accurate list. Organizations should try to partner
with a peer in their region or the state HIM or hospital association to make this tracking as easy as possible.
Next, organizations should confirm the patient’s encounter in-
formation is correct. At times there may be differences in names
due to marriage, birth date, divorce, et cetera. Organizations
should check their internal systems from the HIM and billing
perspectives because this information is obtained from the data
should be able to speak to the charges submitted and for which
the organization received payment.
Organizations should be sure their documentation speaks for
Tools for managing a RAC audit should capture
enough detail to drive process improvements, also.
exchanged between their fiscal intermediary (FI) or Medicare
Administrative Contractor (MAC) and the contractor. If internal
efforts come up short, the FI or MAC can provide direction.
Organizations also should take into consideration combined
accounts or the 72-hour rule (three-day payment window).
From a billing perspective these accounts are combined, but
from an HIM perspective, these encounters are maintained as
separate visits. To ensure the organization’s billing is justified
within the medical record, all documentation supporting charges billed for payment should be submitted.
Some records are bundled and some remain separate. Ac-
cording to a memo from the Centers for Medicare and Medicaid
Outpatient non-diagnostic services that are related to an in-
patient admission must be bundled with the billing for the
inpatient stay. An outpatient service is related to the admis-
sion if it is clinically associated with the reason for a patient’s
inpatient admission… As part of the process, hospitals would
be required to maintain documentation in the beneficiary’s
medical record to support their claim that the preadmission
outpatient non-diagnostic services are unrelated to the ben-
eficiary’s inpatient admission. 1
At times these services will affect DRG assignment. The record
Medical Record QA
Organizations involved in the RAC demonstration project noted
the importance of performing quality assurance (QA) on medical records when responding to requests. However, as the healthcare
industry moves through a time of
increased regulatory presence,
many are grappling with the question of how much QA is enough.
A first step in the QA process is to ensure the organization
has the basic documents requested by the RAC and to ensure
the right person is validating this information. The type of request will and does affect who the right person for the job is.
For example, outpatient audits may require a thorough review
of charge details to ensure all documentation is submitted appropriately.
At the facility level, organizations should identify which individuals are most suitable in assisting in the QA process through
trending and monitoring and implement training and adjustments accordingly. Organizations should use a checklist for requests and institute process change if there are issues.
Some factors that may also affect the process are the varied
encounter dates the RAC may request. Incomplete records, including dictation and signatures, should be completed before
they are sent to the RAC.
Organizations should implement a process to prioritize records that need completion to ensure RAC deadlines are met.
Obtaining the appropriate information to complete a record is
much easier than fighting a denial after the fact. It may be useful
to review CMS Transmittal 327 CR 6698, “Signature Guidelines
for Medical Review Purposes,” to address common problems
If a record has been denied because it was not complete or
received in time, organizations should review the remittance