DRG or Clinical Validation
Our CDS nurses currently query for clinical validity during the concurrent review process. Our Denials Department has requested we work on a process to assist them in avoiding denials. We have formed a committee of coding, compliance, CDI, and denials to develop a collaborative process. Does anyone have a process that is working for their facility that they would be willing to share? Thank you.
Vickie Smith BSN, RN, CCM, CCDS | Clinical Documentation Specialist-Manager | 740-779-7548 | vsmith@adena.org Adena Health System | Clinical Documentation Integrity Program
272 Hospital Rd. | Chillicothe, OH 45601
Vickie Smith BSN, RN, CCM, CCDS | Clinical Documentation Specialist-Manager | 740-779-7548 | vsmith@adena.org Adena Health System | Clinical Documentation Integrity Program
272 Hospital Rd. | Chillicothe, OH 45601
Comments
I would be interested in this as well.
Thank you.
Donna Fisher, CCS, CCDS, CHC
UF Health Shands
fishdl@shands.ufl.edu
I would be interested as well.
ellen.ellis@mymlc.com
We have 4 teams, each focusing on a specific area:
Medical Necessity
Behavioral Health
Clinical Indicators/DRG/Coding
Technical
We are in the process of separating out and building an outpatient denials team.
Our Clinical Indicator team includes our physician advisor, a Coder 3, insurance specialist, an analyst and myself.
Our top clinical indicator denials are for:
Respiratory Failure
Sepsis
AKI
Encephalopathy
Our objective is to prevent the denial from ever occurring by making sure that the coding is supported in the record. We have provided and continue to provide education to our physicians and other providers on our "high risk" diagnoses and are continuing our efforts to get physician agreement on clinical indicators.
We also have provided extensive and ongoing education to our CDI's and Coders on clinical indicators for the "high risk" diagnoses and on the need to query if there is not supporting evidence. We have worked closely with coding to place queries to rule out one time diagnoses that tend to "slip" into the chart, particularly in the discharge summary!
We share examples of denials and the financial impact of denials with our physicians, coders and CDI staff. I think this has been an effective tool to illustrate the scope of the denial problem. I think that too often we are reluctant to share denials with our physicians and other staff. How can the improve their documentation if they don't see the actual denial?
I'm happy to answer any questions on our processes.
Cynthia Mead RN CCDS
Cynthia.mead@nahealth.com
Flagstaff Medical Center
928-773-2374
Thanks Laurie, this is an area that we have really been focusing on for several years.
I just ran numbers for the last 3 years for a meeting with our physicians and was surprised to find that we don't really have any "problem providers" when it comes to denials.
The biggest issue I've found is how to attribute the denial. Our hospitals employ hospitalists who manage the majority of inpatient care. If I assign the denial to the admitting physician then my top 5 physicians are those who only admit. If the denial is attributed to the attending it's a different set of physicians with a bit overlap if the attribution is to the discharging physician. We don't attribute any cases to the residents or ED doctors.
When I presented the findings to the physicians they were very quick to pick up on the attribution issue.
I think the only way I could get more specific data would be to do a manual review of records to see who was the first MD to enter a diagnosis but and our physician leadership didn't think there would be sufficient value in that exercise to justify the time that it would take, making me very happy!
One of the things I'm working on now is trying to link denials to queries that either were not answered or had answers that were a less than helpful response. I've built a tracker into our data management program that allows me enter query information so I should be able to pull data tracking how many denials had queries. I'm also reviewing to see if a query "should" have been placed on the denied diagnosis.
Another area we are tracking is the CDI and the Coder who were assigned to the denial. I have great plans for doing some analysis, primarily looking for education opportunities but it will take some time.
Cynthia
I provide 'the' definition that has been validated and approved by our Medical Staff for the particular clinical topic
Example (partial).
The following definitions, reviewed by physician subject-matter experts, are offered as a reference.
Altered Mental Status Definitions:
Delirium - Misperceptions of sensory stimuli and, often, visual hallucinations. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. A change in cognition that is not due to an established or evolving dementia. Disoriented first to time, then to place, and then to person. (Posner, et. al. Plum and Posner’s Diagnosis of Stupor and Coma. 2007)
Dementia - An enduring and often progressive decline in mental processes owing to an organic process not usually accompanied by a reduction in arousal. Memory impairment, cognitive disturbances, May include: aphasia (language), apraxia ( impaired ability to carry out tasks though physically able), agnosia (failure to recognize objects despite intact sensory function), disturbance in executive function. (Posner, et. al. Plum and Posner’s Diagnosis of Stupor and Coma. 2007)
Stupor - A state of baseline unresponsiveness that requires repeated application of vigorous stimuli to achieve arousal (Neurology in Clinical Practice, 5th ed., Walter G. Bradley, DM, FRCP, 2008)
Coma - State of unresponsiveness in which the patient lies with eyes closed and cannot be aroused, even with vigorous stimulation. (Posner, et. al. Plum and Posner’s Diagnosis of Stupor and Coma. 2007