Advice for a Denied Case

vdavis2

We received a denial for a seconday diagnosis from an Insurance Company. The auditor wants to remove a secondary dx (which is a cc) that a CDS queried for concurrently. The MD ended up answering the question post-discharge. The auditor stated the query posed by the CDS didn't "list ALL of the reasonable choices," therefore the query was considered leading. We were told that we should have listed "uncontrolled HTN" as a choice. We were referred back to the chapter specific coding guidleines for HTN.
We are trying to decide the best way to defend this case (if there is one.) Would love to hear everyone's thoughts!

Query: "Can you further specify pt's type of HTN as: Malignant, Accelerated, Unable to determine, Other:_________. Pt admitted with B/P 157/109, known HTN, medications adjusted."

The pt's B/P was elevated for 3 days during a CHF exacerbation. Pt was on home medication. (The B/P was never noted to be resistant to treatment, untreated, uncontrolled, controlled, etc.) Just noted as "HTN." Med changes: Home meds included Lisinopril 2.5 po daily, Coreg 6.25 BID, Bumetanide 1 mg BID. Admit meds: Lisinopril 5 mg po daily, Metoprolol 25 mg po BID, Coreg 6.25 BID. Day two: Increased Lisinopril 10 mg po daily, D/C'd Metoprolol. Lasix 40 mg IV changed to 40 po for discharge.

ddouthit

When we query for HTN our choices are malignant, accelerated, benign essential, other more appropriate diagnosis, unable to determine. We list all clinical indicators like you did below. If you have listed other more appropriate diagnosis as a possible choice, you have given physician opportunity to document another diagnosis, so I do not think leading.

Dorie Douthit, RHIT,CCS
CDI Program/HIM

annnd2009@gmail.com

Of prob agree. Even using your format I would have at least said rt
Accel
Malignant
Unrelated to accelerated or malig
Other
Unable to determine


I also would be hesitant without iv med intervention

I know nothing about audits but my opinion.
Ann

Unknown

Hmm. I thought the guideline for accelerated/malignant HTN was >/=180/120?

-Jane

Unknown

ICD-9-CM chapter guidelines state
". . .do not use either .0 malignant or .1 benign unless medical record documentation supports such a designation."

In the tabular list of the Ingenix 1012 ICD-9-CM a def is given:
"severe high arterial blood pressure; results in necrosis in kidney, retina, etc.; hemorrhages occur and death commonly due to uremia or rupture of cerebral vessel."


Having said that, I use definitions from an ACDIS journal to decide whether or not to query which listed as follows:
Uncontrolled is not malignant
Accelerated: significant increase over baseline B/P with associated target organ damage
Malignant: as above + papilledema on fundoscopic exam
HTN urgency: severely elevated B/P (S>220 or D>120; no evidence of target organ damage
HTN emergency: requires immediate treatment; increased B/P with target organ damage (CNS, CV, kidney)


I'm not sure I would query for B/P 157/109 - I'd like to see it really elevated. . .

Charlene Thiry RN, BSN, CPC, CCDS
Menorah Medical Center

don.cdi.rn@gmail.com

Just my 2 cents:

First question -- is the diagnosis clinically well-supported? I'm not
convinced:
You've not indicated how high the bp was trending (admit 157/109), for
starters, typically looking for a DBP >120 or 130. You've not indicated
there were any IV meds/gtts administrated to bring the htn under control
(or improved control) (lasix I'd not include as likely more toward the
HF). For malignant -- what were the end organ systems that were
directly affected? what were the acute s/s? (again, cart & horse --
which came first, the acute HF which led to the higher bp, or was it
actually malignant htn that caused the HF exacerbation).
(for a quick overview, see:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001521/ or
http://www.merckmanuals.com/professional/cardiovascular_disorders/hypertension/hypertensive_emergencies.html)


Second point, the AHIMA guidelines (AHIMA. "Managing an Effective Query
Process" Journal of AHIMA 79, no.10 (October 2008): 83-88) clearly
states all clinically reasonable choices:
" Multiple choice formats that employ checkboxes may be used as long as
all clinically reasonable choices are listed, regardless of the impact
on reimbursement or quality reporting. The choices should also include
an “other” option, with a line that allows the provider to add free
text. Providers should also be given the choice of “unable to
determine.” This format is designed to make multiple choice questions
as open ended as possible." -- page 6 of 9 from my internet copy printed
5/2010.

My concern with your query is 2 fold: I am not convinced the pt likely
had malignant/accelerated (nearly but not quite synonymous terms) htn vs
uncontrolled vs hypertensive urgency; and more importantly the query AS
WRITTEN is incomplete and really only offer's specific options that are
for cc's when other clinically reasonable options do exist
(uncontrolled, urgency).

I believe it to be CRITICALLY IMPORTANT from a compliance POV to
include options in multiple choice queries that DON'T affect the DRG
assignment when those are clinically reasonable. Not all subscribe to
this thought.

Don

Donald A. Butler, RN, BSN
Manager, Clinical Documentation
Vidant Medical Center, Greenville NC
DButler@vidanthealth.com ( mailto:mDButler@vidanthealth.com )

mdominesey

I think an important consideration to echo Don's sentiments below is that all secondary diagnoses can/will affect the SOI/ROM of the case regardless of whether it is a CC or an MCC. While only Maryland pays on the APR-DRG system, nearly all reporting agencies - Healthgrades, Carechex, HospitalCompare, LeapFrog - consider severity and ROM, not just CC's.

It is important to include all reasonable choices, but one should not feel compelled to list a poor choice with a checkbox under the guise of compliance. Your compliance will be provided by your reasonable choices and your inclusion of "other" and unable to determine.

Now if they write in a poor, non specific diagnosis.... then there's another query opportunity! (lemonade?)

Mark



Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
Clinical Documentation Excellence
Sr. Clinical Documentation Improvement Specialist
Sibley Memorial Hospital

Information Technology
5255 Loughboro Rd NW
Washington DC, 20016-2695

W: 202.660.6782
F: 202.537.4477
mdominesey@sibley.org


http://www.sibley.org

vdavis2

Ok... let me add a further piece of information to complicate this case. Sometimes as CDS's, we query to obtain further specificity in order try to clarify everything in the record before discharge. This helps our coders so they do not have to seek clarification after discharge (which holds up the billing process and slows productivity). What do we do when we are challenged with situations like this one in which we do not agree with the dx because it was not supported within the record. It is the MD's opinion after clarification. (This would not have been an MD that we could have "questioned" the rationale in this case otherwise we would discuss the need for further documentation to support the diagnosis.)

1) Now see what you think...

2) Is the auditor correct in suggesting that we "didn't give all the choices and should have included "uncontrolled" (which is a non-essential modifier)...

After review of this case, if we query for clarification only, these are the reasonable choices we came up with after review of this case… (and since the MD documented accelerated we included that choice). However, we all agreed not to defend this case based on the lack of supportive documentation within the record.

• Accelerated
• HTN, unspecified
• HTN, malignant
• HTN, benign
• Unable to determine
• Other: __________


Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

ssalinas

Benign should have been included in the choices listed. (As noted, 'uncontrolled' is a non-essential modifier which could apply to benign, malignant or accelerated. If just uncontrolled HTN is documented, it defaults to unspecified.) I do feel the query is leading by only listing malignant or accelerated which are CCs. The majority of HTN cases are benign even if uncontrolled. The query was issued to the physician with limited choices which might well have led him to select what was offered even though, as stated below, it was not supported in the medical record.

____________________

katysuegood@gmail.com

From the information provided, I don't think the patient really had malignant or accelerated HTN. We look for emergent treatment and evidence of target organ damage.
Also, I would include benign and/or uncontrolled HTN in the options. We include the options in Our query.

I'd let this one go....

vdavis2

Thank you Everyone! This is actually how we are going to present this case at our next CDI Task force meeting! We will round table about everyone's thoughts, what went wrong, and how to avoid it in the future! I think this one will be a good case example to present!

This chart was reviewed about 7 months after our program launch, so we were very interested in "Optimizing" every chart. Now that we are involved in the denial process, we have a different focus- Make the chart Defendable!!!

Thanks again! -V

Vicki S. Davis, RN CDS
Clinical Documentation Improvement Manager
Health Information Management Department
Alamance Regional Medical Center
Office (336) 586-3765
Ascom Mobile (336) 586-4191
Fax (336) 538-7428
vdavis2@armc.com

"The difference between the right word and the almost right word is the difference between lightning and the lightning bug."- Samuel "Mark Twain" Clemens

don.cdi.rn@gmail.com

I like that phrase: "Make the chart defendable"
(supports the concepts of accurate, complete picture of the patient's
actual clinical condition)

The very good points made by several regarding uncontrolled, urgency &
emergency adjectives are good ones that should have occurred to me as
well with my initial thoughts & response. It is better to shape the
options toward terms/adjectives that enhance the specificity of coding
(such as benign).

And Mark's general point about capturing more specific terms ties into
this. It is difficult to know which terms will actually affect SOI &
other profiling data, but generally more specific terms will influence
profiling more often than non-specific terms.

Don

lspryszak

Another piece of info:

We'll only have to query for "benign", "malignant", etc. for another couple years. These concepts disappear in ICD-10 -- in ICD-10 there's only "hypertension". Period.