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RACTrac report shows increase in outpatient coding denials

Latest report shows RAC denials are being overturned

Latest report shows increase in outpatient coding denials.

Complex denials by Recovery Auditors (RAs) for outpatient coding have risen sharply over the last year, according to the latest survey by the American Hospital Association (AHA).

In the third quarter 2014 AHA survey, more than 1,000 hospitals were asked to rank complex denials by reason, and the results showed 28% of hospitals reporting denials for outpatient coding errors. That number is up from 10% in the first quarter of 2014 and 7% in the fourth quarter of 2013.
Part of the reason could be RAs are focusing more on outpatient coding claims due to the CMS prohibition on inpatient hospital status reviews on claims from October 1, 2013, to March 31, 2015. In the latest survey, only 23% of hospitals reported short-stay medically unnecessary denials, down from 59% in the first quarter 2014. Inpatient coding denials were also down to 25% from 59% over the same time period.
The rise in complex denials related to outpatient coding could have a major impact on hospitals’ bottom line. Among respondents to the latest survey, the nationwide average dollar amount of automated denials was $688, while complex denials averaged $5,615.
However, the survey also found that hospitals successfully appealed RA recoupments 70% of the time. Respondents reported appealing nearly half (48%) of automated and complex denials.
Respondents were still waiting for the results of 59% of appealed claims, with more than 130,000 appeals out of 223,000 awaiting determinations. That number climbs as the appeals reach higher stages, with 62% of claims at the Administrative Law Judge stage nationwide past the 90-day statutory deadline. Respondents from Region D, comprised of Western and Midwestern states, reported 85% of appeals at that level were past the deadline for a ruling.
In addition to the time it takes for hospitals to recover money via appeals, hospitals face the administrative burdens related to the process. They must coordinate across departments to collect information, find the necessary documentation to submit, and write appeals. According to the survey, 58% of hospitals spent more than $10,000 on managing the RA appeals process during the third quarter, with 39% spending more than $25,000, and 9% spending more than $100,000.
Editor’s Note: This article originally published in the APCs Weekly Insider eNewsletter.

Q&A: Leading the physician via query form titles

Got a question? Ask us!

Got a question? Ask us!

Q: A question was raised by some of the members of my staff regarding the titles of queries. If a query is entitled “Sepsis Query” even if it is an open-ended question is it leading?

A: We must remember that we cannot be leading in our query practice; we cannot point out which answer we anticipate. We also do not want to indicate anywhere upon the query form an indication of expected payment or reimbursement based on the answer provided.

For example, you cannot refer to a relative weight based on multiple choice answers, or which answer is a CC/MCC. Labeling a query with a title can also be interpreted as leading. In your example “sepsis query” may indicate the answer you wish to receive is “sepsis.” I have seen queries for functional quadriplegia labeled as such and this is leading in nature. Another famous query that is often titled with the answer is “acute blood loss anemia.” So use caution in titles of queries.

Because of our software programs, we often categorize queries by subject so that when you are looking for the template for “acute respiratory failure” you can easily find it in your template dictionary. Although it is fine for it to be labeled in your system that way, the version seen by the provider should not be titled. You can understand how it would appear leading to query for a respiratory function clarification when a multiple choice answer is “acute respiratory failure” and the title of the query is the same. You may not intend to lead, but the provider will have a very good clue of exactly what answer you are “banking” on.

Professional of the Year award nominations open

awardsDid you or a colleague launch a successful CDI program in your hospital? Or maybe you helped advance your program beyond CC/MCC capture rate to collaborate with the quality or utilization review teams? Did you or a colleague come up with an innovative way to help physicians understand the importance of CDI efforts or maybe you worked with ACDIS national as a chapter leader, conference committee member, or provided insight to the CDI Talk network?

If you’ve done any of these things or know a colleague who has made significant contributions to the CDI field, who makes a difference in the profession, and an outspoken advocate of CDI, please let us know. ACDIS is now accepting nominations for the prestigious CDI Professional of the Year and Recognition of CDI Professional Achievement awards.

Winners will be honored during the annual ACDIS Annual Conference. To nominate a colleague or peer, please click on the link and complete the form. All nominations will be reviewed by the ACDIS Conference Committee in conjunction with ACDIS administration, and winners will be notified in March.

Q&A: Query for biventricular heart failure

Don't get overwhelmed! Just ask for help!

Don’t get overwhelmed! Just ask for help!

Q: Our cardiologists like to document “biventricular heart failure.” Is a query needed to clarify systolic and/or diastolic?

A: A query should be issued for the chronicity and type of heart failure when the physician states only “biventricular heart failure.” Biventricular represents that both ventricles have mechanical problems, but it doesn’t specify which phase of the cardiac cycle (systole or diastole) is encountering a pumping/filling issue.

If you have access to an encoder and type in “biventricular heart failure” you will receive prompts to add in participating factors, and asked to choose what type of heart failure (systolic, diastolic, combined, etc). If you pick “unspecified,” you end up with code “428.0 Congestive heart failure, unspecified.”

Editor’s Note: Vicki Sullivan Davis is CDI manager at Cone Health System at Alamance Regional in Burlington, North Carolina, and past-speaker at ACDIS National Conference. Contact her at

Guest Post: The (CDI) importance of serving others

Kelli Estes

Kelli Estes

by Kelli Estes, RN, CCDS

Any leadership book you read will quickly point out the importance of serving others! Who can we include as likely candidates for the CDI Team to serve? All healthcare providers: Physicians, nurse practitioners, physician assistants, coders, any variety of others.

Unfortunately, the idea of going above and beyond the proverbial call of duty to serve providers is often lost. I have worked in numerous hospitals where the CDI team exhibits heightened frustration over the lack of provider participation in the CDI program, and over the continued poor documentation that results. CDI team feels forced to find a way to work around this group of difficult providers in order to obtain the improved documentation, in the end, from another provider on the case. This tends to give a “pass” to certain providers who have the tendency to discount the importance of  CDI compliance.  sually this results in an incessant flow of behind closed door mouthing without ever obtaining a workable solution for the future. Sadly, this only sets the table for a negative attitude toward the group of difficult providers.

So what is the CDI Team to do? First, maintain the proper perspective!

Any well-oiled machine has all the moving parts working together at the appropriate time. CDI can be a very complex process that involves input from several different parties to get it all right. Undeniably, everyone has to own their part, but it would behoove any CDI team to provide whatever is necessary to encourage the providers to incorporate CDI into their busy and demanding schedules.

Before you “boo” this entire idea, think about those providers who require repeated queries for the same things, over and over. Most often when I ask CDI specialists if these providers answer their queries, the answer is yes. I remind them that this is still a “win” for the CDI team. Remember why the CDI team is in place. Undoubtedly, the vast majority of providers will begin to document certain conditions unprompted; however, don’t become discouraged when some providers require ongoing CDI queries; that is precisely why CDI is so valuable to the overall continuity of improved documentation.

Secondly, talk to the providers! Taking the initiative to set up a time to talk with difficult providers and explain the “why” behind your need for clarifying queries is a necessary step to facilitate CDI participation. Physicians often get saturated with a great deal of information when CDI programs are first implemented then fail to hear much else beyond that point. Ask providers how you can better serve them in future CDI efforts. Do everything you can to help them realize that you are there to help and be a credible resource for their future documentation improvement needs. Express your willingness to cater to their individual requests within reason. This will allow the difficult providers to recognize that the CDI team can help improve their documentation without completely disrupting their day.

Nevertheless, you may continue to face some barriers such as:

  • The CDI specialist (or team) does not understand a disease process well enough to discuss the need for clarification with confidence.
  • There is a lack of administrative support for fostering a collaborative relationship between the CDI program and providers regarding CDI initiatives.
  • There is no CDI physician liaison in place.

If any of these are the case at your facility, consider the following:

  • Employ the CDI team member most knowledgeable about a particular disease process when discussing with a provider.  Allow a newer CDI staff to come along for the conversation and be mentored.
  • Provide case studies to administration that demonstrate the positive effects of provider participation.
  • Provide other case studies that support the need for a physician liaison. In the meantime, use physicians with whom the CDI staff have a great relationship to discuss difficult cases prior to approaching providers.

Despite our best efforts, we will never completely rid ourselves of those challenges presented by difficult providers, but maintaining an attitude of serving the providers will always prove to be a successful approach to gaining a win for the CDI program.

Editor’s Note: Estes has spent more than a decade as a CDI specialist and consultant, presently with DCBA Inc., in Atlanta. Estes has also been involved in CDI program follow-up assessments and has written several articles for DCBA’s monthly newsletter, CDI Monthly, where this article was originally published. Contact her at

No more ICD-10 delay: Contact your local legislators today

ICD-10 implementation is not game. Tell your elected officials to stop playing around with the implementation date.

ICD-10 implementation is not game. Tell your elected officials to stop playing around with the implementation date.

Word has begun circulating throughout the healthcare industry that ICD-10 may face additional delay.

A letter drafted by Republican Michigan Representative Fred Upton and Republican Texas Representative Pete Sessions on behalf of the Medical Society of the State of New York seeks an additional two-year delay in the implementation of ICD-10 until October 1, 2017. You can read the letter here:

We at ACDIS strongly oppose further delay to ICD-10. Hospitals and CMS have already conceded with prior delays, at great cost: CMS estimated that the last delay cost the healthcare industry up to $6.8 billion in training, software, and other investments.

Further delay would result in additional costs, and also hurt patient care. The nation’s current coding and disease classification system, ICD-9, is out of date and desperately in need of the additional specificity that is the hallmark of ICD-10. Contrary to statements made in the above letter, improved coding specificity is not just tied to reimbursement, but also quality of care and patient safety.

It goes without saying that a further delay would also greatly damage the work already being done by CDI departments across the country, many of which have been diligently collaborating with their physician staffs with formal education and queries for the additional specificity needed under ICD-10.

ACDIS has received permission from our friends at the American Health Information Management Association (AHIMA) to share the following information with our members. It includes AHIMA’s recommended approach to contacting your local legislator and making your voice heard.

If you click this link, it will take you to Capwiz, a tool that makes it very easy to send letters directly to Congress: The form is pre-populated with reasons why the industry opposes efforts to delay ICD-10. This can be sent verbatim, or modified with your own thoughts and experiences with using ICD-10. The ACDIS advisory board stresses that you should urge Congress to act now, rather than wait to voice your opinion on the fate of ICD-10.

Congress is due to recess for the year on Friday, December 12. Time is of the essence, so please take action now.

If a delay is to occur, we all need to know in order to prepare and plan for 2015.

In addition, if you’d like to do more, consider the following course of action as recommended by AHIMA:

Call the leaders listed below TODAY and tell them that ICD-10 is needed in 2015.
Follow these 4 steps:

  1. Call Chairman Upton at 202-225-3761.
  2. Ask for the Health Legislative Aide
  3. Use the talking points below:
  • Do not delay ICD-10. We need the code sets in 2015!
  • According to a recent survey, small physician practices are expected to spend between $1,900—$6,000 to transition to the new code set. This is much lower than previous reports. The study can be found on
  • Physician practices do not use all 13,000 diagnosis codes available in ICD-9. Nor will it be required to use the 68,000 codes that are in ICD-10. The majority of the code increases are due to laterality-which is not currently available in ICD-9.
  • CMS offers a robust plan for physician practices to transition to ICD-10. The Road to 10 can be found here:

When you are done, call the other congressional leaders and Tweet also.

Name Phone                              Twitter Handle
Fred Upton 202-225-3761 @RepFredUpton
Pete Sessions 202-225-2231 @PeteSessions
House Speaker John Boehner 202-225-6205 @SpeakerBoehner
Minority Leader Nancy Pelosi 202-225-4965 @NancyPelosi
Kevin McCarthy 202-225-2915 @GOP Leader

Tweet your Representatives and be sure to use the following #s! #ICD10Matters #ICD10NoDelay

On behalf of ACDIS, thank you for making your voice heard on this important issue.


Brian Murphy

Director, ACDIS