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Guest Post: Tips for appealing MS-DRG denials

Sam Antonios, MD

Sam Antonios, MD

by Sam Antonios, MD, FACP, FHM, CPE, CCDS

Over the last 18–24 months, health- care organizations have seen a surge in MS-DRG denials, sometimes referred to as clinical validation denials.

When reviewers from Medicare Advantage health plans, Recovery Auditors, or other private or contracted health plans analyze a clinical case submitted for reimbursement, they may determine that a particular disease should be removed from the claim. They argue that the clinical documentation in the medical record does not support the diagnosis submitted. In the vast majority of these cases, the removed diagnosis is a CC or MCC, which causes the MS-DRG to shift to a lower payment.

MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In some circumstances, the volumes have been over- whelming. There have also been reports of cases where denials have been egregious, unjustified, or made with disregard for the treating physician’s opinion.

Although there is no surefire way to win an appeal, here are some tips to increase the likelihood of overturning MS-DRG denials.

One: If you believe the case has merit, file an appeal, even if the variance in dollar amount is insignificant. It may be tempting to let go of denials that minimally affect the reimbursement, but when the treating provider’s documentation is available, complete, and accurate, and the coding is correct per official coding guidelines, organizations should appeal. This maintains consistency and makes the appeals about data integrity, rather than payment.

Two: Write clearly and summarize first. The appeal reader will likely not want to spend a lot of time figuring out the intent of the appeal. The first few lines need to describe the clinical case and need for appeal succinctly. Additional details can be included in later paragraphs.

Also, remember to reference review articles, clinical guidelines, or other findings to support your appeal.

Three: Learn how to navigate the electronic health record (EHR) to find relevant information. The history and physical and the discharge summary may not capture the entire clinical picture.

Learn where to locate, and how to decipher, emergency department documentation, consultant reports, progress notes, nursing notes, and other provider documentation, which can often include vital information to a support an appeal.

Additionally, respiratory notes can reveal the status of the patient, including lung exams, respiratory effort, and need for respiratory treatments. The goal should be to offer a complete and accurate clinical picture of the patient.

Four: If possible, review records from transferring facilities to help describe the patient’s case. These records are likely scanned into the record later in the patient care process, but they should be collected before an appeal. Creatinine levels, electrolytes, and other laboratory findings can help differentiate acute and chronic symptoms and conditions.

Five: Keep track of denials electronically. Preferably, use denial-tracking software. If such software is not available, or too costly for your facility, spreadsheets can be just as effective. Remember to update and back up these records regularly.

Editor’s note: Antonios is the CDI and ICD-10 physician advisor at Via Christi Health in Wichita, Kansas. A board-certified internist, he manages the hospital EHR system, works closely with quality leaders to tackle challenging documentation requirements, and engages with physicians on CDI and quality initiatives. This article is an excerpt from its original which appeared in the Sept./Oct. edition of the CDI Journal. Contact him at Samer.Antonios@via-christi.org.

Note from the Advisory Board: Collaboration begins with appreciation

Paul Evans

Paul Evans

by Paul Evans, RHIA, CCS, CCS-P, CCDS, and Anny Yuen

The debate regarding which profession makes the “best” CDI specialist unfortunately continues. Many facilities and consulting firms, initially trained to believe that only nurses could perform the duties of a CDI specialist, continue to propagate such expectations.

Yet we believe other clinicians (e.g., physicians, physician assistants, foreign medical graduates) and nonclinicians (e.g., coders and health information management [HIM] professionals) also perform well in the CDI role with appropriate training.

When considering candidates for an open CDI position, CDI managers need to take a closer look at their initial job descriptions and make sure they accurately reflect not only the current needs of the department and the expanded role CDI specialists need to play, but also changes in industry expectations.

Anny Pang Yuen

Anny Pang Yuen

We’ve seen instances where programs take sample roles and responsibilities wholesale, and fail to customize their expectations or include professionals outside nursing. It has long been ACDIS’ stance that facilities should find the candidate best suited to the particular position. ACDIS has long expressed itself as an inclusive organization, welcoming coders, nurses, physicians, case managers, quality staff, and all who are interested in learning more about the value of complete and accurate documentation in the clinical record.

Further, in order to sit for the Certified Clinical Documentation Specialist (CCDS) credential, ACDIS lists out several levels of required education and skills. Among them, professionals must have an associate-level college degree—as the role of CDI specialist requires a high level of cognitive analysis and the integration of significant clinical acumen and awareness of healthcare reimbursement processes.

On the coding side, educational differences between those holding the Certified Coding Specialist, the Registered Health Information Technician, and the Registered Health Information Administrator® credentials are vast and may include formal college credits, anatomy and physiology, pharmacology, and pathophysiology, among other areas. However, because some facilities do not require coders to have advanced degrees, the conventional wisdom often gets reiterated—that coders in general have no clinical training or knowledge.

As HIM professionals engaged in CDI efforts at our facilities and as active members of the ACDIS Advisory Board, we stand to represent those from the coding side of the house who have effectively leveraged their experience to help advance the CDI mission. We have proven that we can per- form duties as CDI specialists and lead successful departments, while promoting the team dynamic between providers and HIM and CDI.

Not all coders can serve as CDI specialists, and neither can all nurses. Being a CDI specialist takes creativity and strong understanding about clinical documentation and indicators. The first step to true collaboration requires a deeper awareness and appreciation of the talents each individual, regardless of professional background, brings to the table.

Editor’s Note: This article originally published in the Sept./Oct. edition of the CDI Journal.

Review ACDIS advice regarding use of prior information in query creation

Cheryl Ericson

Cheryl Ericson

Last year at around this time, the ACDIS Advisory Board released a white paper reviewing the role of CDI specialists in assessing information in the medical record from prior treatments.

Codes cannot be assigned based on previous conditions. However, there’s a gray area clouding whether CDI professionals can pull information forward to clarify a diagnosis being treated during the current episode of care, says Cheryl Ericson, MS, RN, CCDS, CDIP, manager of CDI services at DHG Healthcare, during an ACDIS Radio discussion on the topic.

ACDIS created the white paper as a means to help CDI programs open a dialogue about such concerns within their facilities and to help CDI managers begin to craft policies and procedures around compliant and ethical practices regarding electronic health record interrogations.

It states:

In particular, CDI specialists face the dilemma of whether to apply information from prior encounters when querying a physician in order to clarify a diagnosis documented in a current admission or episode of care. The CDI profession is divided on this topic: Some are comfortable referencing the historical information within the query when it clarifies a currently documented condition relevant to the current episode of care; however, others believe this practice violates Uniform Hospital Discharge Data Set (UHDDS) definitions regarding an episode of care, as well as coding guidelines.

The paper reviews overarching guidelines and weighs various references such as reporting additional diagnoses and the definition of the term “encounter,” to help CDI programs begin to assess their own practices.

In Arizona where Judy Schade, RN, MSN, CCM, CCDS, works as a CDI specialist at Mayo Clinic Hospital, the population includes a large

Judy Schade

Judy Schade

number of “snowbirds,” retirees who travel to warmer climates for the winter. For these patients, information included in the electronic medical record often represents an important link between the current encounter and conditions which may have developed in another setting since their last hospital visit.

“We might not have the most current information so we need to be careful and to ask the provider where additional information may be needed to validate a diagnosis and pull it forward,” Schade says.

“It’s not enough for the physician to say this is a complex patient,” Ericson says. “They have to document it. If someone has hypertension they’re clinically always going to have hypertension. However, we cannot automatically make that assumption in coding that’s why the physician has to document ‘history of,’ or ‘chronic,’ or something else that is affecting this episode of care and the resources directed toward treating it.”

Such information “is so much more accessible” due to extensive use of electronic health records than it was in the past, ACDIS Director Brian Murphy says. CDI specialists need to determine whether looking back in the medical record, or opting not to look back, artificially limits a CDI professional’s ability to capture diagnosis specificity or whether concerns regarding the compliance of such activities are valid.

For example, Schade cautions that CDI specialists could be pulling forward outdated or inaccurate information as well intentioned as they may be. So “partner with different departments to formulate your policies. We’re moving in a different way of looking at things so we really need to carefully examine this process and develop the best practices,” she says.

The white paper walks through some common concerns but also recommends reviewing recommendations from the Joint Commission, CMS, and your own facility’s compliance, IT, and coding policies, for example.

Editor’s Note: This article originally published in the free eNewsletter CDI Strategies. Subscribe today!

Back to basics: The key skills that represent the cornerstone of CDI success

Wendy De Vreugd

Wendy De Vreugd

During a conversation regarding what basic elements CDI programs need at the onset in order to be successful, ACDIS Advisory Board member Wendy De Vreugd, RN, BSN, PHN, FNP, CCDS, MBA, Director Case Management Case Management and Clinical Social Work
University of California Irvine Health offered the following suggestions. Contact her at wdevreug@uci.edu.

  1. Selecting staff: Matching CDI key skills/qualification/experience to the CDI role and CDI needs of the facility (academic, community hospital, access hospital, product lines). Staff members also need to be an effective trainer and engaged learner to be able to internalize the CDI mission and explain it to physicians and ancillary staff. Having skills in communication/negotiation (vs. introverted) and knowing one’s own strengths and weaknesses goes a long way in being successful in this role.
  2. Assessing where to start: New program managers (or those tasked with starting CDI reviews) need to understand administrators’ top priorities and focus area for the program. The first task is to meet (or exceed) those expectations in order to move the program forward and meet some of the larger programmatic targets suggested by industry leaders. (Advancing beyond CC/MCC capture and straight Medicare record reviews.)
  3. Creating the return on investment (ROI): Regardless of whether your program is a single CDI staff shop or led by a manager and team of coworkers, those involved need to understand the mission and the metrics used to measure the program’s efforts toward its goals. Providing those metrics to the team and keeping that information sharing going through administrative outcome reports (showing quality progress and revenue/CMI capture) not only ensures transparency but effectiveness as well.
  4. Standardizing queries: As this is the CDI program’s most essential tool, spend some time studying the evolution of physician query practice guidance from AHIMA and ACDIS. Queries do need not be scripted. In fact, each must contain the critical clinical information related to that particular patient encounter. Yet, the program needs comprehensive policies and procedures in place as to how to draft a compliant query, how to follow up with physicians, how to track queries, and how to escalate matters if necessary.
  5. Building critical relationships: As CDI professionals essentially work as intermediaries between physicians and coders as translators between the clinical and coding languages establishing effective relationships with these core groups can’t be understated. CDI teams should meet regularly with HIM/coding staff to share documentation integrity concepts. They should feel enabled to ask coders questions about new guidelines and coding conventions. CDI staff also need to obtain input from other departments such as wound care, pharmacist, respiratory therapist, nursing, ICP, etc.)

These are just a few of the essential ingredients, to be sure. If you’re just starting out and want some additional information, feel free to reach out to Wendy or any of the members of the ACDIS Advisory Board. Learn more about them at our website.

Note from the Director: ACDIS announces new timeline for advisory board applications and elections

The ACDIS advisory board recently announced a new timeline for applications and elections to serve on the board. Beginning in 2017, the application period will open in mid-January. Candidates will have three weeks to complete their application. A committee will review applications and narrow the pool of applicants down to a group of finalists, who will be selected by a popular vote of the membership in mid-March. The results of the election will be announced in early April and our new board members will be introduced at that time.

Each year four new board members are voted on and four rotate off.

In 2017, ACDIS will open up the application period on Monday, January 9, and it will run through Monday, January 30.

Why should you run for the ACDIS advisory board? ACDIS advisory board members are engaged in the CDI profession. They are forward thinkers, with a positive vision of evolution of the CDI profession. They must be ACDIS national members in good standing and possess the CCDS certification.

ACDIS advisory board members learn from each other and the ACDIS membership, whom they serve. They are content experts who provide insight on our quarterly membership calls, contribute to our position and white papers, and speak on panel sessions at the ACDIS conference.

Above all they care about the CDI profession and want to make a difference in healthcare.

If the above sounds like you and something you want to be a part of, we encourage you to apply.

You can view the complete list of qualifications here, as well as the nomination and election process and frequently asked questions: http://www.acdis.org/membership/boards#advisory.

You will also find a list of presently serving ACDIS advisory board members and their email addresses; they are happy to answer any questions you may have about the requirements, time commitment, and benefits of board service.

We look forward to your application! Please keep an eye out for the official opening of the application period on January 9.

A Note from the Director: ACDIS Advisory Board responds to new definitions of sepsis, septic shock

ACDIS Director, Brian Murphy

ACDIS Director, Brian Murphy

As reported in the March 3 edition of CDI Strategies a joint U.S. and international task force recently revised the definitions of sepsis and septic shock. The new definitions and revised criteria were published in the Feb. 23 Journal of the American Medical Association .

The new definitions of sepsis and septic shock are quite different from current definitions and significantly raise the bar for diagnosis. More or less, the task force equates this new definition of sepsis (Sepsis-3) with what was once “severe sepsis,” and also implemented a Sequential Organ Failure Assessment (SOFA) for its diagnosis, as well as Quick SOFA (qSOFA) bedside criteria for patients likely to have sepsis.
Since publication of this news, ACDIS has not been idle. We covered the news first on the March 2 ACDIS Radio with Dr. Richard Pinson and Dr. James Kennedy.
Then, led by the efforts of Dr. Sam Antonios, the ACDIS Advisory Board drafted a response for the ACDIS membership, summarizing the new changes and issuing some recommendations for how members should address them in their institutions and published the position paper New Definitions of Sepsis and Septic Shock: Response from the ACDIS Advisory Board.
Finally, Antonios on behalf of the ACDIS Advisory Board recently followed up with the principal authors of The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) in a subsequent letter that details some of the documentation and coding issues the new definitions have raised. We hope that the task force responds in a meaningful way that we can share with you, the ACDIS membership. ACDIS plans to publish this letter in an upcoming issue of CDI Journal.
I’d like to thank our ACDIS Advisory Board members for their work in responding to the new definitions. And to our members, please stay tuned for further information and guidance from ACDIS on this important issue.
All the best,
Brian Murphy, ACDIS Director

News: Voting open for ACDIS advisory board–make your selections now!

If you are an ACDIS member please vote for four new volunteers to represent you on the Advisory Board.

If you are an ACDIS member please vote for four new volunteers to represent you on the Advisory Board.

Voting is now open for four ACDIS advisory board positions, for terms of service starting in 2016 through the end of 2018. ACDIS members may log on to the ACDIS website with their username and password to select the four candidates they believe are the best fit for the association, and then cast their vote. They may only vote once.

The results of the election will be announced at the end of January.

ACDIS advisors are important, volunteer positions that help shape the direction of the association and provide leadership, expertise, and representation for the membership. The term of service is a maximum of three years. Please take a few minutes out of your day to read their bios and cast your votes.

The voting page (http://hcpro.com/acdis/advisory_board_poll.cfm) includes the nominees’ background in CDI and information on why they are seeking election. You must select two RN licensed candidates, one MD, and one HIM/coding professional from three separate groups. The vote will close end of business day on Friday, January 15.

If you have any questions, please e-mail ACDIS Director Brian Murphy at bmurphy@acdis.org.

Best regards,

Brian Murphy, CPC
Director, Association of Clinical Documentation Improvement Specialists (ACDIS)
Danvers, MA
781-639-1872, ext. 3216
bmurphy@acdis.org

ACDIS Updates: CCDS webinar tomorrow, membership Quarterly Call Thursday

Changes took place.

Changes took place.

CCDS Webinar

Tomorrow, Wednesday, August 19, from 1-2 p.m., ET, our own CCDS Coordinator Penny Richards, CPC-A,  joins Cheryl Ericson, MS, RN, CCDS, CDIP, AHIMA-Approved ICD-10-CM/PCS Trainer and Fran Jurcak, MSN, RN, CCDS, for a free, 60-minute webinar exploring the most frequently asked questions regarding the Certified Clinical Documentation Specialist (CCDS) credential and examination process. During the call, the panel will  discuss:

  • How to apply
  • How to prepare for the exam
  • What resources are available for study
  • Re-certification processes

In addition to the agenda, speakers will be answering questions live. To register, visit “CCDS FAQ: Everything You Need to Know About Taking the ACDIS CCDS Certification Exam.”

Join us for an audio conference regarding malnutrition documentation and coding.

Join us for the ACDIS Quarterly Conference Call Thursday, Aug. 20

Quarterly Conference Call

ACDIS members can dial-in to a free topic-focused telephone conference call with leaders and Advisory Board members this Thursday, August 20, from 1-2 p.m., ET. This quarter’s agenda includes:

  • Pulling past medical history forward from EHR for CDI purposes
  • Ethics and ethical CDI practices
  • The role of the physician advisor in CDI
  • ICD-10-CM/PCS
  • Your Q&As

We want your ideas and questions!
If you have a question to ask the ACDIS advisory board, or general suggestions for discussion on the upcoming call, please e-mail Associate Director Melissa Varnavas at mvarnavas@acdis.org.

Conference calls are a great way to ask a question, air any and all CDI concerns, or gather input on a policy or procedure at your hospital. ACDIS members have access to this and all the Quarterly Conference Calls Archives on our website www.acdis.org. While we cannot guarantee your question or discussion point will be addressed on the call, we will try to work in as many as possible.

Please note that due to heavy call volume, we recommend that you dial in 10 minutes early. Dial-in instructions were set to ACDIS members via email this week. If you are an ACDIS member and did not recieve your instructions, call our customer service department by no later than 11 a.m. on the day of the live call at 877-240-6586 or email customerservice@hcpro.com

We look forward to talking with you then!

Advisory Board Voting set; cast your ballot today

January may not feel like election season; most of the pomp and star-spangled banners of the political season fluttered down months ago. Nevertheless, the ACDIS (electronic) ballot box has been primed and dusted, ready for the amazing new candidates who stepped forward this year.

More than 50 volunteers submitted their resumes to the nomination committee. The committee, made up of four members of the existing advisory board, administration, and an at-large ACDIS member, have reviewed the applications, interviewed candidates, and selected 12 individuals from various professional backgrounds as finalists for the ACDIS Advisory Board.

Now it is up the ACDIS membership to review the candidates’ information and choose the individuals you believe will best serve the association for the next three years.

Remember, voting is open only to ACDIS members. Voting instructions are included on the top of the voting page. You must cast four votes total: two votes in group one, and one vote in groups two and three. Once your vote is cast your access to the voting page will be closed to prevent any individual from voting twice.

Note, too, that we are grateful for every one of the individuals who took time to submit their nomination to serve on the advisory board.

Voting will close at the end of the day (11:59 p.m., Eastern) on Thursday, January 29. Please click on this link and login to your ACDIS account to vote. 

The candidates are:

  • Group 1 (RN background): Claudia E. Baker, Terri McCubbin Graves, Melinda Matthews, Karen Newhouser, Judy Schade, and Paula Tatum
  • Group 2 (MD background): James P. Fee, Thomas W. Huth, and Charles E. Pitzele
  • Group 3 (HIM/coding background): Krystal Haynes, Melissa K. McLeod, Anny Pang Yuen

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: http://www.mssny.org/MSSNY/Practice_Resources/ICD-10/ICD-10-Boehner-Letter.aspx

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: http://capwiz.com/ahima/issues/alert/?alertid=63887791. 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 www.coalitionforICD10.org.
  • 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: http://www.roadto10.org.

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.

Sincerely,

Brian Murphy

Director, ACDIS

bmurphy@acdis.org