Continued denial for ABLA- Clinically validated but decision upheld

Recently received a denial for ABLA (this dx was not queried)based upon:

Allegation:

The clinical findings do not reflect Acute post hemorrhagic anemia coexisted during the hospital course.  Lab results: 6/6/18 Hgb 9.3, 6/6 PN VS stable, Labs results 6/7 Hgb 8.4, order of iron supplements but not documented as given prior to discharge. 

This was only part of the clinical picture despite their accessibility to the entire medical record:

(1) Patient w/ EBL of 250ml

(2) Post-op HR: 102-106 

(3) New Order for Type and Screen

(4) New order for Niferex 150mg QD, administered by the nurse and documented as given X1 (not given day of discharge)

(5) Pre-op H & H: 11.4 & 34.7, POD #1 H & H : 9.3 & 27.8 POD #2 H & H: 8.4 & 24

(6) Supporting physician documentation in PN:

·       Abnormal H/H Lab results noted ·       Abnormal HCT 24 noted, Assessment: post-op anemia secondary to acute blood loss, PLAN: iron supplementation, fluids ·       “Patient’s HH dropped from 9.3/27.8 yesterday to 8.4/24.0 today.  Will start Niferex.  Will need to monitor her HH.”DC Summary documentation:  ·       “A medical consult was obtained to assist with management of patient’s medical co-morbidities.  Patient was treated for acute blood loss anemia secondary to surgery with fluids and iron supplements.” 

Active Comorbidities: Post-op Anemia secondary to acute blood loss

We included 2016 "Strategies for Management of Post-operative Anemia in Elective Orthopedic Surgery" which stated that the best practice transfusion threshold was 8g/dl or less or when symptomatic (E.g. tachycardia unresponsive to fluid resuscitation) and otherwise additional strategies such as use of oral iron therapy. 

We wrote the appeal letter and it came back denied again.

What am I missing??

Comments

  • edited January 3
    I don’t think you missed anything at all, as you have acute changes in H/H noted and stated as due to loss of blood, and this is monitored, evaluated and treated.  I can’t offer any tips or help because I disagree with the denial.  Blood transfusions are not ‘required’ in order to code anemia.

    I know this is frustrating, and this seems like an unjustified and arbitrary denial.

    Paul Evans RHIA CCDS
  • These are difficult, but I have had few that were overturned. The reviewers often look at the post-op H&H as a standard in care and not increased monitoring and they often believe the drop is due to hemodilution from fluids in surgery.   In the similar cases that I had overturned, I cited decreased endurance with physical therapy and I was able to argue that it was not hemodilution based on lab values.
  • I have similar cases that are in a second level appeal right now.  I'll agree w/ Paul that you haven't missed anything.  The insurance company is being unreasonable and the denial is unjustified.  I'm sure you've already tried this approach but we are reiterating the definition of a secondary diagnosis per the coding guidelines and how ABLA meets that definition in that particular patient, as well as using Section I.A.19 of the guidelines and CC 4th quarter 2016 Clinical criteria and code assignment.
  • I’d actually emphasize the documentation charted about the ABLA is very, very strong, and much more detailed than that I typically see around this clinical topic.   Again, IMO, the 3rd party is being unreasonable and also not following proper and required reporting requirements.  
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