Denials, denials.....query validity question

afloyd24

We had a recent denial based soley on a query.

Actual query:
Patient with "? pneumonia" stated in PN, started on Levaquin 250mg PO daily x 5 days, CXR shows "pneumonia with associated atelectasis in the left mid to lower lung zone".
Please see choices below in regards "Pneumonia"

Please clarify the following:

( ) The above diagnosis was present on admission and is now resolved
( X ) The above diagnosis was present on admission and is still being monitored, evaluated, or treated
( ) The above diagnosis was ruled out
( ) The above diagnosis is still a likely, suspected, probably diagnosis
( ) Other: _____________________________________
( ) Unable to determine

The selected choice is noted above. It was denied based on the fact that the CDS diagnosed the patient with Pneumonia (not the physician), and the patient was discharged the 12th of the month and the query answered on the 15th after the patient was discharged. That's when we send a large percentage of our confirmed or ruled out queries.

I would love to heard some thoughts on this. This is the first such denial we have received but the denials we are getting recently seem to be absolutely crazy.

Thanks,
April Floyd, RN, CCDS
Director Clinical Documentation
Anderson RMC
601.553.6299

evanspx@sutterhealth.org

I am confused as it seems the CDI was actually asking the MD to indicate if the PNA was actually present "or" had it been ruled out, and this is based upon physician documentation.

If the MD confirms the condition was indeed present, then I see no logical reason for this denial. (Curious: Were the 5 days of antibiotic treatment completed).

Also, there is nothing in the literature stating a retrospective query is not compliant.

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

rachel.layne.mack@gmail.com

I agree with the below statements - this query was credible/valuable and asking what our treatment was directed towards. When you say "denial" do you mean they are taking away money for this chart? Or it's just at a second level review process?

Rachel Mack, BA, RN, MSN, CCDS
Clinical Documentation Integrity Educator
CDI Supervisor - St. Vincent, St. James, & St. Francis
SCL Health – 12600 W. Colfax Suite A-250, Lakewood, CO 80215
rachel.mack@sclhs.net
303-403-7925

ddouthit

I definitely think your query was compliant. You did not introduce a diagnosis you were just seeking clarification of a questionable pneumonia. We are definitely able to query retrospectively for clarification of documentation. Did patient have a d/c summary at time of d/c? Is it possible that d/c summary was dictated after query was answered and could further substantiate the diagnosis of pneumonia?
I would reference the AHIMA practice brief for your appeal.

We have been bombarded with crazy denials from one particular Medicare supplement insurance. APPEAL, APPEAL, APPEAL.

Good Luck!

Dorie Douthit RHIT,CCS
AHIMA-Approved ICD-10-CM/PCS Trainer
ddouthit@stmarysathens.org

sharon.cooper@owensborohealth.org

We get these all of the time, mostly from Humana Advantage plan subcontractors. We appeal, appeal, appeal. Sometimes we win, sometimes we lose, because we only have three level of appeals with them (we appeal all three if nec); and no option to request an ALJ hearing. We use the practice brief and even show our query compared to an example given in the practice brief and they are exactly the same -- they look for any way to deny, whether they are right or wrong! They also misinterpret coding guidelines all of the time in order to deny.

Sharon

Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation/Appeals

sharon.cooper@owensborohealth.org
(270) 417-4612 Office
(270) 316-9088 Cell
(270) 417-4609 Fax

Owensboro Health Regional Hospital
P.O. Box 20007
Owensboro, KY 42304-0007

annnd2009@gmail.com

Hi,

I don’t know if this matters but I always try to make each choice a stand alone answer rather than saying do you agree with “anything above”

I would say:
> Actual query:
> Clinical indicators: progress note states "? pneumonia”, CXRAY shows ""pneumonia with associated atelectasis in the left mid to lower lung zone”.

Treatment: Levaquin250 mg, po x 5days, CXRAY ( especially if repeated- “repeat CXR)
>
>
> Please clarify the following:
>
> ( ) Pneumonia was present on admission and is now resolved

> ( X ) Pneumonia was present on admission and is still being monitored, evaluated, or treated

> ( ) Pneumonia was ruled out

> ( ) Pneumonia is still a likely, suspected, probably diagnosis

> ( ) Other: _____________________________________


> ( ) Unable to determine


I think clearly it’s “looking for a reason” but it might help seem more concrete in the future.

So frustrating!!!

Good luck.

Ann


> On Nov 12, 2014, at 2:01 PM, CDI Talk wrote:
>
> We get these all of the time, mostly from Humana Advantage plan subcontractors. We appeal, appeal, appeal. Sometimes we win, sometimes we lose, because we only have three level of appeals with them (we appeal all three if nec); and no option to request an ALJ hearing. We use the practice brief and even show our query compared to an example given in the practice brief and they are exactly the same -- they look for any way to deny, whether they are right or wrong! They also misinterpret coding guidelines all of the time in order to deny.
>
> Sharon
>
> Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
> AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
> Manager Clinical Documentation/Appeals
>
> sharon.cooper@owensborohealth.org
> (270) 417-4612 Office
> (270) 316-9088 Cell
> (270) 417-4609 Fax
>
> Owensboro Health Regional Hospital
> P.O. Box 20007
> Owensboro, KY 42304-0007
>

debra.stewart@halifaxregional.com

Yes we get these too! And Mostly from HUMANA, APPEAL
Deb


Debra Stewart, RN, BSN,
Clinical Documentation Specialist
Halifax Regional Health System
2204 Wilborn Avenue
South Boston, Va. 24592
(W) 434-517-3317
(C) 434-222-9884
Debra.stewart@halifaxregional.com

deanne_wilk

I have worked with facilities all across the US and the number one
"thorn" for audits and rejections seems to be Humana.

Deanne Wilk, BSN, RN, CCS
CDI Manager
Good Samaritan Health System
4th & Walnut Streets
PO Box 1281
Lebanon, PA 17042
Desk: 717-270-4804
Mobile work: 717-679-7926

sharon.cooper@owensborohealth.org

I agree - Commercial & advantage plans! I have had more headaches from them than all of other payers combined over the past 7-8 years --- although, some of our Medicaid advantage plans are moving up rapidly.
Sharon

Sharon Cooper, RN-BC, CCS, CCDS, CDIP, CHTS-CP
AHIMA-Approved ICD-10-CM/PCS Trainer/Ambassador
Manager Clinical Documentation

Owensboro Health
P.O. Box 20007
Owensboro, KY 42304

Sharon.cooper@owensborohealth.org
Office: (270) 417-4612
Cell: (270) 316-9088
Fax: (270) 417-4609

On Nov 13, 2014, at 07:18, CDI Talk wrote:

I have worked with facilities all across the US and the number one
"thorn" for audits and rejections seems to be Humana.

Deanne Wilk, BSN, RN, CCS
CDI Manager
Good Samaritan Health System
4th & Walnut Streets
PO Box 1281
Lebanon, PA 17042
Desk: 717-270-4804
Mobile work: 717-679-7926

evanspx@sutterhealth.org

Generally speaking, I certainly understand and expect potential denials from 3rd parties on occasion given the complexity and some of the degree of subjectivity of our CDI/Coding work. However, what I do not accept is ‘denials’ from personnel with absolute zero apparent knowledge of what constitutes either valid coding and/or a valid and compliant query. I have found there is absolutely no ‘basis’ for some of these denials, rather an auditor will state what is really only an opinion w/o stating or referring to Best Practices, CMS guidelines, Coding Clinic, or so. For instance, stating that a query issued ‘after’ discharge is totally false.

Just needed to vent…but, truly, many of these seem to be fishing expeditions with no basis. CDI/Coders are held to a very high standard with threat of penalty – 3rd parties should also be held to high standards .

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

evanspx@sutterhealth.org

Meant to state that a query issued after D/C IS valid, as long as compliant….there is nothing stating this is prohibited. Any statement o/w is an uninformed opinion with not basis of fact.

Paul Evans, RHIA, CCS, CCS-P, CCDS

Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421

afloyd24

I was out of the office yesterday so sorry I didn't respond.

There was a discharge summary at the time of the query which stated that the patient was treated w/ abx for "infiltrates". Yes, the patient did go home on a round of abx so was technically being treated after discharge. Can't remember what the Pdx was but was not a abx requiring illness. WBC was also elevated. Perfect opportunity for a confirmed or ruled out query.

Our queries are locked and the choices cannot be edited but we are in the process of our EHR upgrade and this will be corrected.

This claim was denied by "yep y'all are correct" and when appealed, was upheld. We did use the AHIMA Compliant Query Practice Brief but did not make a difference as I don't believe that they understand the whole clinical documentation process (or care to).

I agree that these entities who are so quick to deny a claim should have to have more accountability and clear cut standards and guidelines that they follow. Those guidelines should be available to us since they dont' seem to follow our coding and query guidelines.

I'm off my soapbox and just needed some good clinical documentation and coding integrity backup from the group. We lost that one but at least we are in it together....good or bad.

Thanks so much for everyone's input!!

April Floyd, RN, CCDS
Director of Clinical Documentation
Anderson RMC

evanspx@sutterhealth.org

Key point is that any entity transacting in the market is compelled to know and follow the official guidelines...that can't be overstated. So, any guidelines that a 3rd party (insurance company, et al) may wish to enforce that are not consistent with the Official Guidelines are not valid.


The Official Guidelines published by CMS pertain to everyone. (You can't 'make up' your own coding rules - although I have seen many 3rd parties that have tried to do so).


"These guidelines are based on the coding and sequencing instructions in Volumes I, II and III of ICD-9-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings"



The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). These guidelines should be used as a companion document to the official version of the ICD-9-CM as published on CD-ROM by the U.S. Government Printing Office (GPO).
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-9-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are included on the official government version of the ICD-9-CM, and also appear in “Coding Clinic for ICD-9-CM” published by the AHA.
These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in Volumes I, II and III of ICD-9-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Volumes 1-2) have been adopted under HIPAA for all healthcare settings. Volume 3 procedure codes have been adopted for inpatient procedures reported by hospitals. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses and procedures that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

ddouthit

Well said...the issue we have run into here with Humana is that even when we appeal...all the way up to 3rd Level appeal it is like they are not even reviewing our appeal letter or the supporting documentation that we are submitting, just continuing to deny.

Dorie Douthit RHIT,CCS
ddouthit@stmarysathens.org

evanspx@sutterhealth.org

Good luck with them, Dorie. That seems unfair -and possibly like a violation of their contract?

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421

evanspx@sutterhealth.org

afloyd24

Well said everyone! Paul, your answer is outstanding! And we are keeping track of the crazy denials we are receiving and plan to use them when we renew our contracts. We feel that they are not complying with the same rules that we are so plan to work this into our contracts if possible.

Thanks for the input!

April Floyd, RN, CCDS