Appeals

redjay2redjay2
edited May 2016 in CDI Talk Archive
Going to help out doing appeals for a while. Anyone have any sources for education or sample letters?
Thank you,
Judy Valitutto, RN(clinical document)

Comments

  • Unknown
    edited May 2016
    Judy,
    I have also been moved over into the appeal world at my facility.
    American Hospital Association did have an excellent tool available called the AHA Appeal Handbook.
    We bought it a couple years ago. You might look for that.

    Tina Simpson, BSN, RN, CCDS
    Clinical Denials Management Coordinator/CCDS
    White River Medical Center
    Batesville, AR
  • redjay2redjay2
    edited May 2016
    Thank you so much for the info.I am wondering if I am out of my mind to do this. I do enjoy the investigation,I like challenge but I will be working with the coder. To share the clinical piece.so,I will let you know.
    Thanks the heads up.
    Judy.
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    I have written quite a few appeal letters, and in my view, there are two
    components:

    1. Clinical
    2. Coding

    I have found the RAC sometimes employs either RNs and/or
    credentialed-coders (RHIT, RHIA) that are rather 'new' to the coding and
    compliance world - subsequently, they sometimes will apply some aspects
    of the written rules of coding (Final Rule, Coding Clinic) either out
    of context, or they will apply a very narrow point of view as they issue
    their findings. Quite often, an out-of-date rule stated in Coding
    Clinic will be cited, and the auditors seem to be unaware that the
    advice found in Coding Clinic can change over time.

    So, from a technical coding point of view, one must ensure the auditor
    is 'applying' the coding rules consistently.

    Regarding clinical topics, the reviewers, unfortunately, may state they
    do not 'endorse' key diseases that are clearly stated by clinicians
    within the body of the record - from my point of view, the auditors
    sometimes do not seem to be applying the latest clinical definitions
    advocated by medical specialty groups - I find this disconcerting.
    The reviewers will state something such as ' even though XXX is stated
    in the record, this condition does not meet "OUR" definition of
    condition XXX'. It is interesting that no firm definition of the
    condition question will be referenced in the correspondence from the
    auditor.

    So, it is important to cite the clinical definitions and sources one
    uses to define and document disorders, and it is important to cite the
    rules in Coding Clinic, in context. Do not simply 'accept' that the
    auditor has correctly applied the coding rules - they don't always do
    so, in my opinion.




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

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
  • sharon.cooper@owensborohealth.orgsharon.cooper@owensborohealth.org
    edited May 2016
    Research, research, research!! The denying entities have become so creative in trying to take away your money; you have to be just as creative in keeping the money you earned. Use Coding Clinics, Official Guidelines, federal regulations, the Federal Register, LCD's, NCD's, state regulations, local standards, standards of care, standards of practice, journal articles, previous rulings, etc. If you billed/coded correctly - appeal, appeal and appeal - to the ALJ, to the MAC, to the DAB, etc.

    As far as coding, there are so many Coding Clinics that are "gray", the denying entities tell you how they think they should be applied.

    If the denying entity is correct in their findings - make it a learning experience for those involved, to prevent the same scenario from happening again.

    We added denial management related to DRG changes 4 - 5 years ago; we have grown and are now responsible for all denials in the hospital - inpt, outpt, governmental (including RAC's, MIC's, ZPIC's), commercial, medical necessity, DRG's, Quality of Care, Infusion Center, Cancer Center, and so on. We have just recently added denial management for our Acute Care Rehab (IRF) unit and our Transitional Care Unit (SNF) - which has been quite a learning curve - currently trying to understand RUG Codes.

    There were very few robust auditing agencies when I started doing appeals - now there are many with others jumping on the band wagon faster than we can keep up!

    Good Luck Judy! Your experience will bring a lot to the table; and you will learn even more which will help you to grow in your CDI role if you return to that position.

    Sharon


    Sharon Cooper, RN-BC, CCS, CCDS, CDIP
    AHIMA-Approved ICD-10-CM/PCS Trainer

    Owensboro Medical Health System
    Manager Clinical Documentation & Appeals
    P.O. Box 20007
    Owensboro, KY 42304-0007
    (270) 688-1277 Office
    (270) 316-9088 Cell
    (270) 688-2737 Fax
    sharon.cooper@omhs.org

    TEAM = Together Everyone Accomplishes More!
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Sharon: You have a very robust program regarding denials and any forms
    or procedures you might share would be greatly appreciated.

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

    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
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