therapeutically treated should be coded as secondary
diagnoses. In this instance, _________ should be
reported as a secondary diagnosis due to the following
documentation: __________.
d. Extended length of stay; or
e. Increased nursing care and/or monitoring; or
f. Has implications for future health needs”
Or
As stated in the Official Guidelines for Coding and
Reporting, “Any documented significant condition that
impacts care and is treated should be coded. A condition
is clinically significant when it has implications for the
patient’s future health care and/or requires any of the
following:
______________ was documented in ______________and
treatment administered in the form of _______________.
a. Clinical evaluation; or
b. Therapeutic treatment; or
c. Diagnostic treatment; or
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The decision to appeal can be complex, and organizations
must ensure that the documentation contains solid evidence
and support for their appeal. There may be cases where the
internal impact of the appeal process outweighs the appeal
itself. For example, organizations must determine if they want
to use time and staff to argue a random denial of $100 when it
could take hundreds of dollars in staff and legal resources to
defend it. At times, it can be a matter of principle. Organizations
may find that the decision to appeal a denial may need to be
made on a case-by-case basis.
During the RAC’s short history, providers have had success
in overturning denials during the administrative law judge
stage. Providers should not rely on this stage solely, but it does
offer some optimism for a nonbiased judgment. Providers may
need the expertise of an attorney to handle the motions at this
appeal level.
Discussing and outlining the RAC process helps organizations remain on their toes in this time of increased scrutiny.
It is crucial that providers stay abreast of regulatory issues as
they will continue to increase in the coming years. Medicaid
RAC is just around the corner. ¢
AUDIT-TRACKER®: Audit Process
Management & Tracking for Internal & External
Audits
; Facilitates tracking Requests, Denials,
Appeals and Take-backs; Includes sample
letters; Import, scan and store all documents
related to the audit; Team/task assignments;
User defined timeframes, appeal levels, and
email notifications; Real time dashboard
highlights overdue actions, financial impact,
and more
References
Centers for Medicare and Medicaid Services (CMS). “Medicare
Reconsideration Request Form.” Form CMS 20033. Available
online at https://www.cms.gov/cmsforms/downloads/
cms20033.pdf.
CMS. “Medicare Redetermination Request Form.” Form CMS
20027. Available online at https://www.cms.gov/cmsforms/
downloads/cms20027.pdf.
CMS. “Request for Medicare Hearing by Administrative Law
Judge.” Form CMS 20034AB. Available online at https://www.
cms.gov/cmsforms/downloads/cms5011a-b.pdf.
CMS. “Statement of Work for the Recovery Audit Contractor
Program.” Available online at https://www.cms.gov/RAC/
downloads/Final%20RAC%20SOW.pdf.
Sharon Easterling ( sharon.easterling@carolinashealthcare.org) is assistant vice president for Carolinas Healthcare.
℡ 800-274-1214
www.FirstClassSolutions.com
www.Cortrak.com
www.Audit-Tracker.com
For the preceding articles in this series, see “RAC Forensics 101:
Part 1: Medical Record Requests and the Discussion Period” in the
January 2011 issue and “RAC Forensics 101: Part 2: The Results Letter
and the Discussion Call” in the February 2011 issue.
