Denials

katysuegood@gmail.comkatysuegood@gmail.com
edited May 2016 in CDI Talk Archive
I'm wondering what sort of involvement your CDI department has in the Denial/RAC process? In our case, RAC's/Denials are handled by a Nurse auditor for medical necessity and coding staff for DRG Denials. The nurse auditor is in our department but we have virtually zero involvement. I feel like there are ways in which we could be helping but I'm not exactly sure where to start. I see the obvious connection with DRG Denials. It is my understanding that the DRG's are often denied because they are denying the sole CC/MCC that is driving the DRG. If they can get rid of that one Dx, they can deny the DRG. We should be helpful in this regard because we should be adding additional CC/MCCs which makes us less vulnerable to denials. However, I'm not sure how to assist with medical necessity. Especially since this is not and will not be our primary role. We would just be providing some sort of support.

Thanks for the help!

Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • ddouthitddouthit
    edited May 2016
    Katy,

    Our CDI team does all DRG denials for RAC and commercial. Yes, auditors tend to focus in on accounts with only one MCC/CC. One way CDI can help defendability of charts is on the front end. When you have that one CC or MCC ask the physician do document the clinical indicators in detail that he is using for the diagnosis. This makes it much easier on the back end to defend if a denial is received.
    Our Case Management Department handles all Medical Necessity so I cannot speak much to that. Your Case Management department should be able to give you specific DRGs that are under scrutiny for Medical Necessity and CDI can work to shore up documentation on the front end for those focus DRGS.

    Dorie Douthit, RHIT,CCS
  • vdavis2vdavis2
    edited May 2016
    Good Advice Dorie!!! :)

    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
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Thank you!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • Unknown
    The RAC DRG Denials at our facility are handled by the Coding Supervisor and myself (CDI supervisor). We review and defend every one that we can and have been very successful. I review from a clinical standpoint and the coding supervisor defends from a coding standpoint. We have a great team!

    Juanita "Nita" B. Seel, RN CCDS, CDIP
    Supervisor Documentation Integrity
    Greenville Hospital System University Medical Center
    Greenville, SC 29605
    jseel@ghs.org
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