Denial Prevention?

katysuegood@gmail.comkatysuegood@gmail.com
in CDI Talk Archive
Aside from ensuring accurate CC/MCC capture, what does your team do to reduce Denial (RAC/insurance) vulnerability in your institution, if anything?. We have recently been experiencing many denials that claim that a specific diagnosis was not substantiated in the record. Things like Resp Failure, Shock, Renal failure and Sepsis. Often these were well documented throughout the record. Sometimes they site criteria (RIFLE, for example), sometimes they do not. We have recently been seeing a wave of Denials regarding Renal Failure. I know many other facilities are seeing this as well. Is there anything you do concurrently to try to mitigate this risk. Are you querying for clinical indicators? Do you have a face-to-face with MD’s if you do not see criteria being met? Do you have standardized criteria you reference when reviewing records (RIFLE, sepsis, etc?).
To Clarify, I am not talking about an obvious diagnostic error like the MD stating ‘Hyponatremia’ instead of ‘hypernatremia’. I am talking about diagnoses that are more ambiguous and generally are diagnosed based on a cluster of symptoms/studies. Is it our responsibility to question the MD clinical judgment and/or ask them to substantiate their diagnosis with clinical indicators?

Thanks!


Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404

Comments

  • wrightnawrightna
    edited May 2016
    We have been querying our physicians (paper query sheet) for clinical
    indicators being used for things such as sepsis & renal failure when we
    don't see criteria being met. We, too, have gotten recent denials
    similar to what you stated. At first, we were reluctant to question the
    providers diagnosis as well. However, the outside auditors, RAC's , etc.
    are pulling out all their "tricks" when attempting to deny any
    particular case or diagnosis so it then became a necessity. We will have
    documentation in daily progress notes throughout the stay and then a
    particular diagnosis (say encephalopathy) doesn't make it to the
    discharge summary and the auditor/ payor will state something to the
    effect of "since the diagnosis wasn't carried through to the discharge
    summary the provider must have felt like it wasn't important enough" and
    therefore they want to take back payment.

    Our facility has defined criteria for ARF/ AKI (we are a transplant
    facility), sepsis. We are still struggling with (agreed upon)
    definitions for resp failure (in abscence of ABG's) & resp insuff. by
    our providers.

    Our CDS team here agrees that individual chart reviews today for CDI
    take much longer than they used to a few years ago. We certainly have
    job security though!!

    Our CDS & coding professionals review all denials and CDS who was on
    the case concurrently is the one who gets to review and then write the
    rebuttal letter to the various outside agencies.

    Nancy Wright, RN, BHA, MBA
    Clinical Documentation Specialist
    Health Information Management
    Saint Mary's Health Care
    200 Jefferson SE
    Grand Rapids, MI 49503
    PH: 616.685.6687
    FX: 616.685.3014
    wrightna@trinity-health.org
    www.smhealthcare.org
  • ssalinasssalinas
    edited May 2016
    Am anxious to see the responses to this issue since this is something I struggle with as well, not because of denials but due to the expectation that coders become diagnosticians and question MD's clinical judgment. It is much easier to query for a possible or more specific diagnosis than to question a diagnosis that a physician has documented and directed treatment toward.


    Sharon Salinas, CCS
    Barlow Respiratory Hospital
    2000 Stadium Way, Los Angeles CA 90026
    Tel: 213-250-4200 ext 3336
    ssalinas@barlow2000.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Currently our Coding Manager has been handling DRG Denials which is where these tend to land. An RN from the UR department is handling Medical Necessity Denials. So I don’t think our CDS’ (or MD’s, including leadership) have a great idea on these. They seem to think the “DRG Denials” are related to incorrect coding (or they should be fought). I have spent a significant amount of time working on these with our coding manager and providing the feedback that I do not feel the coding is wrong, that this really is an issue of the MD’s not including justification of their diagnosis in their documentation.
    To create facility definitions, are you working with an MD liaison? Specialist? Etc? are these defined in a policy? How are your queries worded?
    Sorry for the barrage of questions!

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Exactly, in fact I also feel like in many instances a query does not fix the issue. Especially with "Hospitalists" when we may have many MD's taking care of patients during a given stay. If we query an MD due to lack of clinical indicators concurrently and the MD then decides that the patient doesn’t really meet and responds to that effect in the query, what happens when subsequent documentation still includes this documentation? It sounds like a nightmare!
    I also worry about this impacting our relationship with MD's....


    What really got me thinking about this was that I put together a presentation regarding the new AHIMA query brief and came across this gem.

    “The focus of external audits has expanded in recent years to include clinical validation review. The Centers for Medicare and Medicaid Services (CMS) has instructed coders to “refer to the Coding Clinic guidelines and query the physician when clinical validation is required.”1 The practitioner does not have to use the criteria specifically outlined by Coding Clinic, but reasonable support within the health record for the diagnosis must be present.
    When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation policy.”

    Their examples are basic (hypernatremia when labs point to hypo, for ex) but it seems like this can extend to all diagnoses.



    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • wrightnawrightna
    edited May 2016
    We have a dedicated physician champion with whom we work through & with.
    We also go to the medical directors of the particular service lines if
    we still need additional help/ info. We do not have a policy on this as
    of yet but it is being discussed.

    We also have someone in UR who does medical necessity & status denials
    (meaning inpt vs outpt criteria for admit). You are right in that the
    review of these cases can absorb an enormous amount of time when you are
    looking at doing an appeal letter. We have jokingly said we could use an
    FTE just to work on these alone...not because of volume but because of
    the time it takes to put into these!

    As far as wording the query goes, obviously it is on a case-by-case
    basis but essentially something like this. "Noted sepsis documented in
    3/25 progress note. Review of data : WBC 6.0, T 100.2, P 84, R 18, B/P
    126/76, o2 sats 96% on RA. Can you please clarify in an upcoming
    progress note the criteria being used for the diagnosis of sepsis?" The
    provider than will further document clinical findings/ observations or
    will say "sepsis ruled out."

    We have been actively telling our providers when we meet with them the
    types of denials we are seeing. Our physician champion also does our
    in-house physician UR documentation so is aware of what the outside
    agencies are doing.

    Nancy Wright, RN, BHA, MBA
    Clinical Documentation Specialist
    Health Information Management
    Saint Mary's Health Care
    200 Jefferson SE
    Grand Rapids, MI 49503
    PH: 616.685.6687
    FX: 616.685.3014
    wrightna@trinity-health.org
    www.smhealthcare.org
  • carmella.gaycarmella.gay
    edited May 2016
    We have also experienced denials because the diagnosis wasn’t listed in the discharge summary. Please see the following Coding Clinic that states a diagnosis is not limited to the discharge summary….
    When a patient has a lengthy stay and multiple problems the provider is not always going to carry those diagnoses through to the discharge summary, but as long as you can show therapeutic treatment, diagnostic procedures, extends the length of stay, clinical evaluation or increased nursing care and/or monitoring – then it is an acceptable secondary diagnosis. Between the Coding Clinic and the guidelines, we have justified the coding of a diagnosis not found in the discharge summary.
    Coding Clinic, Second Quarter 2000 Page: 17 to 18 Effective with discharges: July 1, 2000
    Question:
    I am requesting clarification of what appears to be conflicting direction between an AHIMA Practice Brief and the Official Coding Guidelines. The AHIMA Practice Brief on Data Quality states that coding professionals may "assign and report codes, without physician consultation, to diagnoses and procedures not stated in the physician's final diagnosis only if these diagnoses and procedures are specifically documented by the physician in the body of the medical record and this documentation is clear and consistent."
    The Official Coding Guidelines ODX #2 states "When the physician has documented what appears to be a current diagnosis in the body of the record, but has not included the diagnosis in the final diagnostic statement, the physician should be asked whether the diagnosis should be added."
    Answer:
    The two statements listed above are not inconsistent, but reinforce each other. When the documentation in the medical record is clear and consistent, coders may assign and report codes. If there is evidence of a diagnosis within the medical record, and the coder is uncertain whether it is a valid diagnosis because the documentation is incomplete, vague, or contradictory, it is the coder's responsibility to query the attending physician to determine if this diagnosis should be included in the final diagnostic statement. All diagnoses should be supported by physician documentation. Documentation is not limited to the face sheet, discharge summary, progress notes, history and physical, or other report designed to capture diagnostic information. This advice refers only to inpatient coding.
    © Copyright 1984-2012, American Hospital Association ("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.
  • Unknown
    edited May 2016
    Here is a novel idea, provide feedback and awareness to physicians on the value of documentation of their thought processes and clinical judgment in their medical decision making, complementing assessment of the patient in the form of conclusory diagnostic statements with thought processes reflective of inherent analytical and problem solving skills. Establishment of medical necessity for the physicians's work performed culminating in E & M assignment is the fundamental basis for physician reimbursement. The CERT contractor consistently identifies lack of medical necessity for physician E & M assignment level as a contributing factor to flat out denials of physician E & M assignment or at a minimum down-coding of the actual E & M assignment. Capitalize upon the synergies of clinical documentation refelctive of medical necessity that clearly exist, the same degree and level of clinical documentation standard can inarguably be made for both the physician and the hospital.

    Thanks
  • paxnerospaxneros
    edited May 2016
    Very interesting issue Katy. We've experienced "documentation happy"
    physicians as of late who are "over-documenting" diagnoses w/o clinical
    indicators. Querying physicians over validations makes me a little
    uncomfortable - I don't want them to see me as questioning their clinical
    expertise.

    I have issued queries asking them to validate a diagnosis by documenting
    clinical indicators within the chart. I present them with CI's we use daily.

    I would appreciate seeing any examples of "reverse" queries anyone may use.

    Norma T. Brunson,RHIA,CDIP,CCS,CCDS
  • cselukecseluke
    edited May 2016
    We experience this issue every so often. We call it the "epidemics" of whatever diagnosis seems to catch the fancy of the providers. I refer them to our physician advisor.

    Cathy L. Seluke, RN, BSN, ACM, CCDS
    Supervisor Clinical Documentation Compliance
    MaineGeneral Medical Center
    Augusta and Waterville, Maine
    P. 207.872.1796
    F. 207.872.1594
    Cathy.Seluke@mainegeneral.org
  • kshumpertkshumpert
    edited May 2016
    I have educated our physicians ad nauseam about RACs I am sure. That being said, our physicians are knowledgeable about the denials and the reason to validate criteria. The reality is that if it is not clarified with a query concurrently, it will have to be argued with the physician input regarding their intent for the diagnosis when denied by the RAC. In essence, tomayto, tomahto. I do leave parameters on the query for a condition, but I don't question the diagnosis. I ask them to clarify their criteria for the condition and I also leave options for ruled out or resolved.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Interim Director Outcomes Management
    Clinical Documentation Improvement Specialist
    Community Howard Regional Health
    3500 S Lafountain
    PO Box 9011
    Kokomo, IN 46904
    Office 765-864-8754
    Cell phone 765-431-0123
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    The entire scenario creates multitude logistical issues and problems for all - particularly 'coders'.

    What will we do IF it is 'felt' a particular diagnosis, say Acute Renal Failure, is the only 'CC' and the patient does not meet or match the facility-accepted criteria for that particular condition.

    Assume either a CDI or a coder subsequently issues a 'confirmation query' for the condition of ARF and the MD either does not respond or responds that 'yes', the patient had ARF.

    Will such a case pass muster with the RAC?

    I see many 'political' quandaries and issues with this process of vetting as well as profound issues with Discharged , Not Final Billed Accounts.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Confirmatory Query Form Attached

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    I agree Paul. The advice to query if clinical indicators are not met is pretty scary to me. It places the CDS/Coder in the position where we are pseudo-diagosticians. We have Hospitalists at our facility so often numerous MD's see a patient during their stay. I know our MD's are pretty hesitant to negate a dx that another MD documented. I would predict that they would often confirm the dx in question but that would not solve the RAC issue.

    In a related story, our coding manager just had a meeting with an MD that is supposed to help her sort out RACs with this issue. The MD was "baffled" by the whole system of coders. She was frustrated that diagnoses were being coded when (according to her read), they did not apply to the patient, even though they were well documented. My recommended response was "would you like to code your own records?". I'm joking of course, it just always amazes me how little understanding most MD's have of the revenue-cycle process. It's not a criticism of them, it has never been an expectation but I find it really interesting/concerning.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Paul,

    I brought forward this issue in regards to sepsis because I recently did a audit of sepsis charts to see if clinical indicators were met. Based on the results, I recommended that we provide some MD education about the need to include indicators and also drafted a query that could be used in the (fairly common) instance where we have sepsis documented early on, possible as a differential dx but it drops off later in the record. I fear these charts sometimes inaccurately end up in a sepsis DRG when really, sepsis was ruled out.
    We have an approval process for query templates. I recently tried to get a basic "rule-in/out" query approved. Our MD liaison squelched it because he said that MD's would be uncomfortable rescinding a dx. I have tried to explain why this is VERY important, but apparently I am not getting through....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Katy - I agree. Doctors are not 'coders', and coding can be very, very complex. I always ask them to simply document precisely so that the coders can paint the proper clinical picture of the case. I am not sure why your doctor in question would be baffled for certain diagnoses that 'did not apply'?

    It is always interesting (and challenging) to deal with the issues of documentation, coding, and impacts upon metrics.

    It seems those of us that CAN properly function as a legitimate liaison are few.

    Paul Evans, RHIA, CCS, CCS-P, CCDS
     
    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell:  415.637.9002
    Fax:  415.600.1325
    Ofc:  415.600.3739
    evanspx@sutterhealth.org
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited May 2016
    Katy:

    It seems your staff does not comprehend that 'many' possible conditions may be initially recorded as 'working diagnoses'. I , personally, have requested confirmation for Sepsis that is noted early in a case, receiving a response that either the Sepsis was present, and is resolving, OR, the Sepsis was suspected, but was ruled out.

    I believe you are pursuing the proper course of action. While it is true that one 'may' code conditions that are 'mentioned only once' - there are many examples in Coding Clinic, this may not mean we should code as final conditions those disorders suspected and later ruled out. "Reliability' of recorded diagnoses can be problematic, in my opinion.

    There is no easy answer for this issue and I feel it is a problem for all of us.

    Did you review the attachment?

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

    Manager, Regional Clinical Documentation & Coding Integrity
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org
  • kshumpertkshumpert
    edited May 2016
    Keep in mind that the RAC is using strict clinical criteria to deny a diagnosis. Additionally, facilities use clinical criteria to justify their appeal. What if the physician was alerted to the possibility of this issue concurrently rather than after the fact? As CDI, you have an opportunity that the RAC does not. You can have discussions with providers in real time to ensure integrity of the record. The goal is not to be a diagnostician, but to communicate with the physician what we know. I never question a physician's diagnosis. I am helping to solidify the documentation.

    Thanks,
    Kathy
    Kathy Shumpert, RN, CCDS

    Interim Director Outcomes Management
    Clinical Documentation Improvement Specialist
    Community Howard Regional Health
    3500 S Lafountain
    PO Box 9011
    Kokomo, IN 46904
    Office 765-864-8754
    Cell phone 765-431-0123
    Fax 765-453-8447

    When something can be read without effort, great effort has gone into its writing. ~Enrique Jardiel Poncela
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes Paul, I agree. The template I drafted was very similar basically stating that we had a dx documented early int eh record by not addressed later. I then asked if the dx was ruled in/out, resolved, still to be ruled out, etc. Yes, while probably/possible dx MAY be coded. I believe they should be looked at closely. If we suspect that they were actually ruled out, it seems we should clarify. ESPECIALLY when we are talking about a diagnosis like Sepsis that will likely drive the DRG.

    The problem is that some of the people that are "up the chain" don’t really have a great understanding of what we are up against.

    I appreciate your input.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    Yes, this is the ideal scenario. However, there will always be instances that are not caught concurrently and the new AHIMA brief is pretty clear that these should be queried on.

    I think it will likely become a complex issue.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
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