ABLA denials
Hi, we are finding that insurance is denying ABLA when there is a significant drop in hgb but provider is continuing to monitor w/frequent labs. My understanding is that this is not unusual across the country. Do any CDI programs have guidelines on when they report ABLA, i.e. a certain amount of a drop in hgb, a hgb below a certain level, ect. or any other guidelines that they go by to appeal with insurance.
thanks
Comments
All coding and CDI professionals may wish to read Coding Clinic, 2Q, 1990, as it provides great discussion on a number of pertinent topics regarding 'what is reportable'
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Clinical Evaluation Defined
Clinical evaluation means the medical staff is aware of the condition and is evaluating it in terms of evaluation, testing, consultations, and clinical observation of the patient’s condition and/or the existence of the condition affect the types or choices of treatment rendered to the patient.
Per Faye Brown, 2006, “Codes should not be assigned for conditions that do not meet UHDDS criteria for reporting. For example, diagnostic reports often mention such conditions such as hiatal hernia, atelectasis, and right bundle branch block with no further mention to indicate any relevance to the care given. Assigning a code is inappropriate for reporting purposes unless the physician provides documentation to support the condition’s significance for the episode of care”
Example: The mention of mild or asymptomatic MVP does not “usually” meet the definition of a reportable condition. In addition, some coders feel it is appropriate to report MVP merely because the record may state something such as: “Echo showed mild MVP”. However, this is NOT a diagnostic statement and this practice is contradicted by Coding Clinic.
This is more complicated than it may seem. There are previous and robust discussions on this thread you may want to search for and review. I'd ascertain 'why' it was being denied? I'd also ensure any drop was not due to hemodilution. I'd review precisely how much blood has been lost acutely, and cite normal H/H and any subsequent drops, linking that to the acute loss of blood. We have a 'rule' that we consider that at least 300cc need to have been lost, and we 'like' to see about a 20% precipitous drop in H/H. As a reminder, it is not required to treat a condition for it to be coded. Clinical evaluation and monitoring alone can suffice; many patients refuse transfusions, and yet they do have anemia.
OVERVIEW of Reportable Conditions (partial)
Coding Clinic, 2Q, 1990
Abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added.
The coder should not arbitrarily add an additional diagnosis to the final diagnostic statement on the basis of an abnormal laboratory finding alone. To make a diagnosis on the basis of a single lab value or abnormal diagnostic finding is risky and carries the possibility of error.
It is important to remember that a value reported either lower or higher than the normal range does not necessarily indicate a disorder. Many factors influence the value of a lab sample. These include the method used to obtain the sample (for example, a constricting tourniquet left in place for over a minute prior to collecting the sample will cause an elevated hematocrit and potassium level), the collection device, the method used to transport the sample to the lab, the calibration of the machine that reads the values, and the condition of the patient. An example is a patient who because of dehydration may show an elevated hemoglobin due to increased viscosity of the blood.
Example 1: A low potassium level finding treated with intravenous or oral potassium is clinically significant and should be brought to the attention of the physician if no diagnosis has been documented.
Example 2: A hematocrit of 28 %, even though asymptomatic and not treated, may have been evaluated by the physician with serial hematocrits. Because this is outside the range of normal laboratory values and has been further evaluated, it is significant enough to ask the physician whether an associated diagnosis should be documented.
Example 3: A routine preoperative chest X-ray on an elderly patient reveals collapse of the vertebral body. The patient was asymptomatic and no further evaluation or treatment was carried out. This is a common finding in elderly patients and is probably insignificant for this episode.
Example 4: In the absence of a cardiac problem, an isolated electrocardiographic finding of bundle branch block is ordinarily not significant, whereas a finding of a Mobitz II block may have important implications for the patient's care and would warrant asking the physician whether it should be reported for this admission.
Example 5: Incidental findings on X-ray such as asymptomatic hiatal hernia or diverticulosis should not be reported unless further evaluation or treatment is carried out.
Codes from section 790-796, Nonspecific abnormal findings, should be assigned only when the physician has not been able to arrive at a diagnosis based on an abnormal finding, but considers it clinically significant enough to list in the final diagnostic statement.
Example 6: The physician lists an abnormal sedimentation rate, 790.1, on the face sheet and has been unable to make a definitive diagnosis during the hospitalization.
Example 7: An abnormal pap smear of cervix, 795.0, is listed in the final diagnostic statement.