When someone in the healthcare industry hears the word “denial”, many things can come to mind. There are many different types and kinds of denials; what could be said about denials could fill a book. To narrow the conversation, let’s touch on one specific type of denial that has become more prevalent for hospitals in recent years.
A documented and coded diagnosis acting as a CC or MCC for the DRG is denied by the payer with the claim that the clinical picture does not support that it is a true and valid diagnosis. By removing the diagnosis code, the DRG is reduced, resulting in a reduced payment to the hospital.
This type of denial has been called various things which can create confusion when assigning the appropriate person to address it.
A few examples are:
Payers have learned how to target the types of inpatient discharges that lend well to this type of challenge. Common targets include DRGs with a single CC or MCC where the CC or MCC is acute renal failure/injury, acute respiratory failure, encephalopathy, malnutrition, or sepsis.
If this is not a coding specific issue, then where does the problem lie? The Center for Medicare and Medicaid Services (CMS) has not stated any one criterion as the official clinical criteria for all to follow. As a result, many payers including the RACs have created their own criteria or adapted existing criteria in the industry such as AKIN (Acute Kidney Injury Network), RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease), or KDIGO (The Kidney Disease: Improving Global Outcomes). Providers most often do not know what individual payer criteria is being used. Physicians have not been educated on when additional documentation is needed to support certain conditions that they diagnose and document.
The coding teams are stuck in the middle. Facilities can trend what different payers are targeting and the basis of their denials. Armed with this information, coders still cannot diagnose the patient. Even with outlined criteria to follow, conditions documented in the record and not ruled out cannot be ignored by the coder. The coder cannot make the determination that a documented diagnosis is not valid and choose not to code it.
What’s a hospital to do? Hospitals should create a team to review these types of denials and fight back whenever possible. Some hospitals have taken the extra steps to create internal clinical guidelines to give direction and promote consistency; however, payers may still deny diagnoses based on their own criteria. Offer as much education on the issue as possible to physicians, CDI staff, and coders.
Who should review and argue the cases? The best person to review these denials and write up an appeal letter would be the very person that documented the diagnosis in question, the physician. However, it is a rare hospital that has a medical staff member with the time and willingness to do so. So, the task should fall to someone with strong writing skills with a clinical background that can create a strong argument in support of a documented diagnosis by outlining the patient’s clinical picture in detail.
From a different angle: Coding was initially created for the primary purpose of statistics and research. Coded data can play a key role in value-based care and other programs based on patient care outcomes and quality of care indicators. While Official Coding Guidelines offer clear direction on when to assign a secondary diagnosis code, the guidelines could be a part of the problem. The guidelines state additional conditions are coded when they affect patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, they extended the length of stay, or necessitate increased nursing care and/or monitoring. But what the guidelines neglect to include are conditions that create a patient health risk for the future.
One example includes patients with morbid obesity that decline nutritional counseling or any other type of intervention. Because the condition is not being addressed, some payers are denying it as a secondary code/s. As patients develop obesity related conditions in the future, there will be limited data for research of obesity related health problems because the condition of obesity is not being coded now. This also could create a problem with quality of care analysis when patients’ conditions are uncontrolled due to unaddressed obesity such as diabetes, respiratory conditions, joint problems, and cardiac disease.
Every denial should be reviewed and where possible and appropriate, challenged. Payers may tend to target facilities that do not argue or fight back. Do not accept a payer’s denial at face value. Review the case. If there is enough clinical support in the record to argue, do so. The continued challenge is what constitutes “enough clinical support”? Not even CMS answers that for us.
VP of HIM Services