Queries in Appeal letters
Are other institutions including Compliant Queries within their appeal letters?
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Are other institutions including Compliant Queries within their appeal letters?
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Yes definitely.
yes we have recently started receiving denials based on a non-compliant query but they have never seen the query because our queries are not part of the medical record. The physician entitled their query response "response to coding query". So far it is just Humana, but they are denying based on that claiming a non-compliant query. So I have had to appeal and include a snipet of the COMPLIANT query.
Cheryl Erickson and Robin Sewell did a wonderful conference presentation on this very topic. I hadn't heard of those types of denials yet, but they are truly crazy!!
How do they know it is a non compliant query, if there isn't one for them to see. Are you saying the physician documented in the medical record "responding to coding query"?
yes!
Yes, we include the query if the auditor/payer is saying "a pre-bill query should have been placed...."
So, after several overturns I now received our first upheld level one appeal from Humana the audit was performed by a unnamed "certified coder" AKA AI i am sure. I will be more than happy to share the upheld rationale here, but basically "AI" certified coder claims has upheld the decision that our query was non-compliant and leading. It also insists that ACDIS/AHIMA Query practice brief is now being accepted by CMS as regulatory!! Not true it is advisory AND they came out with a statement about their practice brief being used as the basis for denials labeling them non-compliant. Kim Conner addressed this in her presentation at ACDIS conference in Mastering the Art of Persuasion: Crafting Effective Denial Appeal Letters. So, I am leaning into what she wrote in my second level appeal that it is a strong and serious accusation to accuse our program of noncompliance. That our organization maintains the highest degree of compliance with federal regulations as well as ADVISORY guidance from the governing bodies for coding and CDI (AHMA and ACDIS). Humana's claims that these standards were not maintained are false. We respectfully ask Humana to clearly identify where each query in question is noncompliant and implies financial reimbursement and/or quality impact. I also refuted the claim that CMS is deferring to ACDIS/AHIMA practice brief using verbiage from Kim's presentation.
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The ACDIS/AHIMA query practice brief has consistently stated that the brief is intended to guide and support query practices.
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These are not regulations, the brief is advisory and best practice.
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The addendum to the brief in 2023 specifically addresses this issue.
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The 2023 addendum specifically states, “Denial trends have indicated that payers have been challenging diagnoses obtained through query by questioning query compliance. These challenges should be evaluated to ensure they reflect compliance versus best practice.”
I just find it funny the auditing company states CMS is deferring to the practice brief as standard practice but when we use it regarding clinical validation appeals they either ignore the argument or state the practice brief is not regulatory but advisory.
Here is the upheld dispute:
Here is the current 2nd level appeal I am working on... I am still waiting for an opinion by my director if we want to actually use the tone or soften it up. It is still professional and respectful. I am of the opinion if we don't start addressing these more aggressively they are going to increase and just as we all get together and chat about what is working and what isn't I am sure auditing companies do as well and this might then start to become a trend with all the auditing companies.
Anyone else having any luck with this or is now seeing this trend of upheld? They are claiming the example statements are leading. Then every multiple choice query with example statements would be considered leading. these are examples... i just have placed the examples section of the query.