Inpatient Clinical Services

Medical Record Reviews:

Inpatient clinical services reviews include the following key performance indicators (KPI):

1) Medical Necessity:

For hospitals participating in the Medicare Fee-for-Service program, medical necessity is demonstrating that a beneficiary is receiving the right treatment in the right setting at the right time.

Now more than ever CMS Functional Contractors (i.e. MAC, RAC, etc.) are scrutinizing hospital records for medical necessity for hospital inpatient admissions.

About This Service
Our medical record audits target case types that have been identified by functional contractors and the Office of Inspector General (OIG) as historically being medically unnecessary inpatient admissions and/or having DRG coding errors.

Our certified nurse auditors utilize criteria recognized by the Jurisdiction 10 Medicare Administrative Contractor (MAC) and the Alabama Quality Improvement Organization (QIO) – Alabama Quality Assurance Foundation (AQAF) as a source for non-physician reviewers in medical necessity determinations.

How You Can Benefit From This Service

Medical necessity reviews enable clients to identify opportunities for improvement that can help prepare your organization as hospitals are being faced with an ever increasing number of Functional Contracting Auditors.

2) Clinical Documentation Improvement (CDI):

CDI is a performance improvement program utilizing a concurrent and retrospective process to promote accurate DRG classification according to regulatory compliance standards set forth by CMS.

Queries should be generated for conditions that seem to be clinically indicated in the record, even when those diagnoses will not impact the DRG assignment.

About This Service
Our nurse auditors identify query opportunities by reviewing records specifically looking for conflicting, unclear or incomplete documentation and provide these findings to our clients.

How You Can Benefit From This Service
Identified clinical documentation query opportunities provide our clients with specific examples as an educational tool to promote future accurate accounting for resources consumed, as well as reflect the severity of the illness of the patient.

3) Core Measures:

Core measures track a variety of evidence-based, scientifically researched standards of care which have been shown to result in improved clinical outcomes for patients.

Acute Inpatient Hospitals are required to collect and report data for core measure performance sets. Currently, data for Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia (PN) and Surgical Care Improvement Project (SCIP) is publicly reported on the CMS Hospital Compare website.

About This Service With the inpatient medical record review, patients with a core measure principal diagnosis are reviewed for documentation of the quality measures in the medical record.

How You Can Benefit From This Service
This review provides hospitals with potential core measure fall outs that can be used to provide specific education to clinical and medical staff.

Additional Service: Readmission Analysis

This is a proactive analysis of a hospital's Medicare Fee-for-Service readmission rates. This is a key area for hospitals to focus on as 14 communities nationwide are participating in the 9th Scope of Work Transitions of Care Project with a focus on reducing hospital readmissions, as CMS begins to share readmission data on Hospital Compare, as the Office of Inspector General (OIG) plans to determine trends in hospital readmissions as part of their FY 2010 work plan and as the current health reform debate has focused on linking reimbursement and hospital readmissions as one way to fund health reform.

What This Service Includes
Our certified nursing professionals perform a confidential and in-depth analysis of a client’s hospital readmissions from Case Mix Index (CMI) data provided by the hospital.

How You Can Benefit From This Service
Our clients benefit from readmission analyses, because it: