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UnitedHealth Group, Inc. vs. the United States of America: The case for CDI, part 2

Brian-Murphy

ACDIS Director Brian Murphy

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America, and my intent to write a series of articles on this civil fraud action. Why? Because I find this to be an incredibly interesting case with broad ramifications for CDI and coding departments.

So let’s review the basic at the facts of the case, starting with the who and when. [more]

Guest Post: Creating an inpatient coding compliance plan

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

To limit exposure to claim denials and external reviews, the best safeguard for a facility is a robust, effective internal coding compliance policy, plan, and program.

Begin by reviewing any existing coding policies and procedures to determine whether they are consistent with the organization’s compliance plan, as well as the latest Official Guidelines for Coding and Reporting. If your department lacks compliance policies and procedures, excellent resources are available at JustCoding, ACDIS, AHIMA and the Hospital Corporation of America.

A facility’s coding compliance plan may be a subsection of the policy. If you format your compliance plan as a subsection, the document should be labeled “coding compliance policy and plan.” The plan component should be much more detailed and include the specifics of what, when, and how often. Each organization should tailor its coding compliance plan to its organization.

When developing a new coding compliance plan, managers should begin by asking these questions:

  • Why am I establishing a plan?
  • What will I review?
  • How will I select a sample?
  • How will I assess accuracy?
  • What action will I take when the results are known?
  • How will I monitor progress?

The coding manager should collaborate with the compliance officer in developing the plan. Some components that should be considered when you create your plan are:

Purpose: The purpose of the XYZ Hospital Compliance Plan is to improve the accuracy and integrity of patient data, ensure minimal variation in coding practices, serve as a conduit to improve provider documentation in the electronic patient record, and support XYZ Hospital’s ability to receive its entitled reimbursement for the services it and its providers provide.

Expectation: Staff (employees and, when applicable, contracted staff) will strive to maintain the highest level of professional and ethical standards in the performance of their coding duties. Staff will be trained and oriented in all applicable federal and state laws and regulations that apply to coding and documentation as relates to their positions.

Adherence to these guidelines is imperative. Where any questions or uncertainty regarding these requirements exists, it is the responsibility of the employee to seek guidance from a certified coding specialist, health information administrator, or another qualified coding professional. Staff will be familiar with prohibited and unethical conduct that relates to coding and billing as outlined in the facility compliance plan. Staff will comply with AHIMA’s Code of Ethics.

Education:

  • All coders, billers, and providers will receive orientation and training in the fundamentals of compliant coding and billing. Continuing education will be provided in the form of handouts, memos, journals, in-services, and formal education as available and approved. To keep up with changes in regulatory requirements, coding changes, and proper coding procedures, it is the staff member’s responsibility to further his or her knowledge by reading all handouts, memos, and journals provided, and actively participating in available in-services and formal education workshops.
  • All coders, billers, and providers will receive training in coding, documentation, and billing compliance issues on an annual basis or more frequently as need dictates. The training will be coordinated by the coding compliance subcommittee in conjunction with or in addition to training provided by the compliance office.

Coding resources: Coding staff shall have access to the following resources to facilitate their coding duties:

  • Encoder
  • Computer with dual monitors
  • Coding books: ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures; other reference materials will be maintained in the coding manager’s office

Coding conventions and guidelines: The guidelines and conventions to be followed for codes to be reported on claims will be:

  • Coding Clinic published by the American Hospital Association
  • Official Guidelines for Coding and Reporting published by CMS and the National Center for Health Statistics

Editor’s note: This article was originally published in JustCoding. Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article is excerpted from JustCoding’s Practical Guide to Coding Management.

 

Guest Post: Relevant ICD-10 code proposals for CDI and coders

Allen Frady

Allen Frady, RN, BSN, CCDS, CCS

By Allen Frady, RN, BSN, CCDS, CCS

Editor’s note: The CMS ICD-10 Coordination and Maintenance Committee (CMC) met on March 7 and March 8 to discuss proposed code changes to ICD-10-CM and ICD-10-PCS. The committee is a federal committee comprised of representatives from CMS and the CDC’s National Center for Health Statistics (NCHS). The committee approves code changes, develops errata, addenda, and any other modification to the code sets. These code changes were discussed in hope of being amended in the 2018 code update, active October 1.

Among the many proposed changes to the code set, I noted 16 of particular interest to CDI specialists and coders. Remember, nothing is final until the September meeting of the CDC Coordination and Maintenance Committee(CMC), and of course, the CMS finalization.

AMI

Some of the most relevant talking points include possible changes related to heart disease. First, the CMC proposes reclassification of an unspecified acute myocardial infarction (AMI) to I21.9 AMI, including “unspecified myocardial infarction (acute) no otherwise specified (NOS).” Currently, “unspecified AMI” defaults to an STEMI. CDI specialists frequently prod physicians for additional specificity to ensure NSTEMI’s are not inadvertently reported as STEMI’s as it also affect quality standards.

Additionally, an unexpected proposal given the recent AHA Coding Clinic, First Quarter 2017, CMC proposes a new code I21.A1, Myocardial infarction type II (also called a Type II MI). Coding Clinic previously directed Type II MI to be coded as an NSTEMI. CMC’s proposal includes myocardial infarction due to demand ischemia and myocardial infarction secondary to ischemic imbalance as inclusion terms. The new proposed code would have a “code also underlying cause, if known” instructional note in the Tabular Index. Examples of precipitating events included in the proposal are:

  • anemia
  • chronic obstructive pulmonary disease (COPD)
  • heart failure
  • tachycardia
  • renal failure

There are, of course, other possible causes and the list provided is not intended to be comprehensive. This hopefully will circumvent the frustration CDI and coding professionals have had with the lack of an index entry for “Type II MI” for the last several years.

Other classifications of MIs exist. There are five in total and among the new code proposals for “other myocardial infarction type” specifies types 3, 4 and 5 as inclusion terms.

End-stage heart failure

Another interesting suggestion for the CDC comes from its recommendation for a new code for end-stage heart failure I50.84, to be used in conjunction with other heart failure codes. This represents potential for assignment to a higher level of severity within both the APR- and MS-DRG systems. There are also new inclusion notes for end-stage heart failure to be reported for the American College of Cardiology (ACC) stage “D” if the physician only writes “stage D heart failure,” it can be coded as end-stage heart failure. Furthermore, new inclusion terms direct the coder that diastolic heart failure and diastolic left ventricular heart failure include heart failure with preserved ejection fraction or with normal effusion. The same goes for systolic heart failure and the term reduced ejection fraction. Additional new codes related to heart failure include:

  • Acute right heart failure (I50.811) with an inclusion term of “acute ISOLATED RIGHT HEART FAILURE”
  • Biventricular heart failure (I50.82)
  • High output heart failure (I50.83)

I was somewhat unfamiliar with high output heart failure so for now, this reference from the National Institutes of Health will have to do:

“The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem.” 

Surgical codes

The CMC proposed a number of updates related to surgical wound infections. There are several new proposals for obstetrics infection codes and there were also proposals for other wound infection codes, such as:

  • 41, infection following a procedure, superficial surgical site which accounts for a stitch abscess.
  • Deep incisional site under T81.42
  • Intra-abdominal abscess under T81.43
  • Slow healing surgical wounds, covered in the includes notes for T81.84, NON-healing surgical wounds per changes to the inclusion notes.

Additional recommendations

CMC has a few other suggestions CDI and coding professional need to note, such as:

  1. Moving late effects of cerebral vascular accident (CVA) from an Excludes I to an Excludes 2 category, which seems appropriate in light of Coding Clinic, Fourth Quarter 2016, p. 40, as well as the 2017 Official Guidelines for Coding and Reporting, advice to override the Excludes 1 note and code late effects when present in tandem with a new current stroke, anyway.
  2. A new code for immunocompromised status which includes terms for immunodeficiency status and immunosuppressed status, Z78.2. ICD-10 code Z78.21 covers immunocompromised status due to conditions classified elsewhere such as HIV or cancer, and Z78.22 immunocompromised due to drugs. In the past, immunocompromised status did provide for additional severity and it’s role in risk adjustment methodologies could expand.
  3. Proposed codes for the pediatric coma scale which could eventually provide some additional severity for cases with catastrophic neurological compromise. In this author’s opinion, these codes would be a welcome additional to pediatric hospitals seeking to properly adjust for their quality, outcomes and mortality metrics.
  4. Codes for nicotine dependence via electronic nicotine delivery systems (e-sigs, anyone?).
  5. Proposals for alcohol abuse, in remission. Also noteworthy, the term “Alcohol use disorder” seems to fall under the codes for alcohol dependence per newly proposed inclusion terms. The same proposals are provided for opioid abuse, in remission as well as cannabis, cocaine, sedatives, etc.

Editor’s note: Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts, answered this question. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Guest Post: Postoperative complication coding and value-based purchasing

by Ghazal Irfan, RHIA

Achieving compliant coding

Postoperative complication coding guidelines continue to cause difficulties for coders and CDI professionals. So, let’s analyze the steps needed to ensure complete, accurate, and compliant coding.

The first step in compliance is defining a postoperative complication. In general, a postoperative complication is an unanticipated outcome (in the form of a condition or a disease) that develops following an illness, treatment, or procedure.

For example, a 60-year-old female comes in for a herniorrhaphy (hernia repair). She has a past medical history of hypertension and morbid obesity with body mass index greater than 40. She smokes and has chronic obstructive pulmonary disease (COPD). Surgery goes well; however, post-surgery, the patient has a hard time weaning off of the ventilator and is immediately given inhaler treatments and placed on BiPAP. After a couple of incentive spirometry sessions and inhaler treatments, the patient feels better, and she is discharged home the following day.

The body of the operative report documents the patient’s inability to breathe on her own due to “acute respiratory insufficiency following extubation.” The header of the operative report, however, documents no complications. How should acute respiratory insufficiency following extubation be coded? Should it be coded as a “postoperative complication,” or as an “acute respiratory insufficiency?”

The ICD-10-CM Official Guidelines for Coding and Reporting states that “code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. The guideline extends to any complications of care, regardless of the chapter the code is located in.”

The Guidelines go on to explain that “it is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification if the complication is not clearly documented.”

Keeping these rules in mind, a coder cannot report the diagnosis as a postoperative complication due to the legal ramifications of these codes, and due to the conflicting documentation: acute respiratory insufficiency following extubation versus no complication.

When to query

While deciding on a secondary diagnosis, coders and CDI specialists need to ask questions like:

  • “Was the condition clinically evaluated, tested, and treated?”
  • “Did the condition result in extended length of stay?”
  • “Did the condition require increased nursing care?”

Patients who are smokers with COPD and morbid obesity have a hard time clearing their lungs of carbon dioxide and need a little help to get the gas exchange going. Since a coder/CDI specialist is not a doctor and cannot assume a cause-and-effect relationship, the coding guidelines will direct them to query the physician regarding postoperative complication.

The following query form can be used for any postoperative complication clarification and should be made part of the legal medical record.

query

Chances are, an inexperienced coder will look at the operative report, assign the postoperative complication code as not present on admission (POA-N), and drop the chart. Such an assignment negatively affects the facility’s quality outcomes report since postoperative complication codes with POA N are counted as the Agency for Healthcare Research and Quality’s patient safety indicators. A seasoned coder/CDI specialist, however, would submit a query and ask for clarification. Accurate, complete, and compliant coding can only be achieved when coders and CDI specialists have leadership support and physician buy-in. Coders need education on the significance of reaching out to physicians when coding postoperative complications, and when documentation is conflicting or inconsistent, even though the DRG stays the same.

Also, managers should not penalize coders for holding charts or failing to meet productivity benchmarks when pursuing a clarification. Code assignment affects reimbursement, quality outcome reporting under the VBP program, and academic research programs. Working collaboratively—coders, CDI professionals, and physicians—can assist facilities in gathering the most complete and accurate data sets, which will result in valid, ethical, and reliable quality outcomes reporting.

Editor’s note: This article originally appeared in JustCoding. Irfan is the coding compliance manager of hospital services for RevWorks AH-Corp and works with her team to ensure revenue cycle compliance. She holds a degree in health information management and is pursuing a master’s degree in biomedical informatics at Oregon Health and Science University. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

Guest Post: Your CDI team’s role in pneumonia value-based outcomes, part 1

Shannon Newell

Shannon Newell, RHIA, CCS

by Shannon Newell, RHIA, CCS

The selection of a principal diagnosis, secondary diagnosis, present on admission (POA) status, and discharge status on each claim determines whether a pneumonia discharge will be included in Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program measures. And effective CDI reviews can capture this documentation.

Pneumonia as a principal diagnosis

CMS includes any discharges with the principal diagnosis of pneumonia (including aspiration pneumonia) in the mortality and readmission outcome measures. Some of these discharges are excluded for various reasons, for example, discharges with a reported discharge status of “against medical advice” are excluded from both measures. The final group of included discharges is referred to as the “cohort.”

Consider the following case studies.

Case study 1: A patient is admitted with pneumonia and acute respiratory failure requiring BiPAP with admission to the ICU along with IV antibiotics for treatment of the underlying pneumonia. Two principal diagnosis options exist–acute respiratory failure or pneumonia. Coding guidelines permit the selection of either option as the principal diagnosis. Today’s CDI teams typically select the option that results in the highest MS-DRG relative weight. Based on current MS-DRG relative weights, the pneumonia would result in the MS-DRG with the highest relative weight, and if it is selected, the discharge would be included in the readmission and mortality outcome cohorts.

Case study 2: A 65-year-old white male with known AIDS is admitted with pneumonia related to his underlying AIDS. Only the pneumonia is addressed during the hospital stay. Based on ICD-10-CM Official Guidelines for Coding and Reporting, AIDS/HIV infection (B20) would be reported as the principal diagnosis, and the HIV-related condition, pneumonia, would be reported as an additional diagnosis. The reporting of AIDS (B20) as principal diagnosis would remove the patient from the pneumonia readmission/mortality cohorts.

Summary

Performance on the CMS 30-day pneumonia readmission and mortality measures adjusts payments received for the Medicare and commercial patient population. By promoting and adopting evidence-based definitions; associated documentation requirements; accurate selection, sequencing, and assignment of POA status; and accurate reporting of discharge status, the CDI team plays a vital role in data integrity for claims-based quality measures.

Editor’s note: This article was previously published in the Revenue Cycle Advisor. Come back to the ACDIS Blog next week for the second part of the article. Newell was previously the director of CDI quality initiatives for Enjoin, but is now retired. Should you have any questions regarding this article, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

 

From the Forum: Using pediatric nursing notes for query creation

From the ACDIS Forum

From the ACDIS Forum

Nursing notes cannot be used for coding and billing purposes. This does not mean, however, that they’re worthless for CDI purposes. Often times, CDI specialists neglect reviewing this documentation because they know it can’t be coded. This is a mistake.

“Often times, it’s the nursing notes that will support queries for encephalopathy, delirium or other altered mental status conditions,” says Karen Bridgeman, MSN, RN, CCDS, CDI educator at the Medical University of South Carolina in Charleston.

While nursing notes can help with clinical indicators to support a query with patients of all ages, nurses’ documentation helps a couple of pediatric-specific diagnoses, for instance, thrush.

“One thing I’ve noted a few times is that nursing usually documents clinical indicators of thrush. The doctor orders Nystatin, but doesn’t document what he/she is treating,” Claudine Hutchinson, BSN, RN, CDI specialist at the Children’s Hospital at St. Francis in Tulsa, Oklahoma, says.

With sticky diagnoses such as malnutrition – an especially difficult diagnosis in pediatrics – nursing notes also often provide valuable information on the patient’s body mass index (BMI), height, and weight. Additionally, the nursing notes often provide clinical indicators to support clinical validity of an already present diagnosis of malnutrition, according to Laurie Prescott, RN, MSN, CCDS, CDIP, CDI education specialist at HCPro in Danvers, Massachusetts.

“Malnutrition in children is based, in part, on their failure to meet developmental milestones and deviations related to their z-score and the pediatric BMI scale,” Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BRL Healthcare in Middleton, Massachusetts, said in response to a question in CDI Strategies.

If the nursing documentation supports a diagnosis of malnutrition based on unique pediatric criteria, then a CDI specialist can use that information to support a query to the physician. Often, nurses record the information used to calculate BMI during the initial physical assessment.

Nurses also often document the present on admission (POA) status of pressure ulcers during initial assessments. Since pressure ulcers fall under the hospital-acquired conditions banner, it is vital to document their POA status. If a physician documents a pressure ulcer, check the nursing documentation for its status upon admission.

We work with our [providers] during rounds to be sure that POA status is documented for any pressure ulcers documented by nursing on the admission assessment,” Jackie Touch, RN, MSN, CCM, CDI specialist at CHOC Children’s in Orange, California, says.

Nursing notes can also provide a valuable education entry point for CDI specialists. “In some instances, it may be as simple as showing the physicians where they can access the nursing documentation. “The physicians did not know how or were unable to view the nursing flow sheets,” at Wake Forest University Baptist Medical Center before the CDI helped address the problem, says Melinda Matthews, RN, BSN, CCDS, manager of inpatient clinical documentation excellence at Wake Forest Baptist Health, which includes Brenner Children’s Hospital in Winston-Salem, North Carolina, in an ACDIS Q&A.

Even though coders cannot use the nursing notes for coding purposes, Prescott advises working the nursing documentation into your regular chart review process.

“[Nursing notes] often assist in understanding the patient’s baseline conditions, and often help us to identify any secondary diagnoses not mentioned in the provider’s initial assessment,” Prescott said in a response to a question in CDI Strategies.

Prescott also advises educating the nursing staff about the usefulness of their documentation in supporting clinical validation and identifying missing diagnoses and opportunities for clarification. The nurses can be a valuable asset in reaching CDI goals, so educate them accordingly, Prescott says.

Editor’s note: This article’s content was taken largely from recent posts on the ACDIS Forum. To participate in the Forum, click here. If you have any questions regarding this or the forum in general, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org.

 

 

Conference Conversations: Brant offers insight into recovery auditor programs

barbara brant

Barbara Brant, MPA, RN, CCDS, CDIP, CCS

Editor’s Note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we spoke with Barbara Brant, MPA, RN, CCDS, CDIP, CCS, a senior consultant with Cotiviti Health Care, presenting “CDI Specialists: Impact Potential in the Audit Process.” Since 2005, she has been involved in the development, implementation, and auditing of CDI programs. Brant has assisted health systems with ICD-10 Gap Analyses and created ICD-10-CM educational materials for specialty physician groups. Currently, she provides training and clinical support for DRG auditors. She lives in Camp Hill, Pennsylvania with her husband Marty.

 

Q: What do you think CDI specialists’ biggest misconceptions about the Recovery Auditor program are?

A: There are really three main misconceptions:

  1. Denials are determined without complete review of the documentation
  2. Recovery Auditor’s only look for “gotcha” errors
  3. CMS Recovery Audit programs are performed to only take back

Q: Recovery Auditors are not at the top of anyone’s best friend list in healthcare, but what important purpose do they serve?

A: The goal of any audit is to identify problematic issues. The purpose of CMS’ Recovery Auditors is to identify and prevent improper payments. Therefore, Recovery Auditors serve a purpose by encouraging healthcare providers to work for solutions to correct identified problems, stabilize provider revenue cycles, and ensure accurate payments for payers.

 

Q: What are three things attendees can expect from your session?

A: The three things that attendees can expect are

  1. To understand that Recovery Auditors perform very comprehensive reviews of all documentation provided.
  2. To obtain knowledge that the guidance for recommended reimbursement changes (higher or lower) is based on extensive peer-reviewed research of best-practices, clinical consensus data and Official Coding Guidelines.
  3. To use information from this session for improved denial data due to CDI performance improvements.

 

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: To encourage use of retrospective audit data to concurrently improve problematic documentation

 

Q: What are you most looking forward to about this year’s conference?

A: Interaction with colleagues and to stay updated on CDI’s expanding roles within the revenue cycle

 

Q: Fun question: what’s your favorite movie?

A: A Christmas Story – a perfectly imperfect loving family!

 

Book Excerpt: Review all charts to maintain a compliant CDI program

Trey La Charité, MD, FACP, SFHM, CCDS

Trey La Charité, MD, FACP, SFHM, CCDS

If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-insurance and charity cases. The reason for this directive is multifaceted. First, reimbursement certainly is not the only purpose of a CDI program’s efforts. Even if a particular payer reimburses on a per-diem (per-day) basis or by a different DRG system (i.e., APR-DRGs), meaning there may not be any reimbursement benefits to improved documentation, CDI efforts still offer significant gains.

In particular, every payer employs some form of risk adjustment methodology to compare the outcomes of care between different providers. In other words, a facility’s providers look better to an insurer if they achieve the same results as a competing facility’s providers but do so caring for sicker patients.

Second, the need for a particular patient’s hospitalization must be justifiable. It doesn’t matter how many high-dollar diagnoses a CDI professional identified in the medical record if the payer – be it Medicare or private insurer – denies the claim. The sicker the patient is – both in fact and on paper – the harder it is for an auditor or a payer to justify that the patient should never have been admitted at all or that the patient should have been cared for in observation as opposed to being admitted as an inpatient.

If a CDI program is understaffed and simply does not have the resources to review all charts, program goals should evolve such that more than just the Medicare cases are reviewed. In other words, a CDI program should not be reviewing only Medicare patients.

If a CDI program reviews only Medicare cases, the government and the Office of Inspector General (OIG) believe that hospitals preferentially targets Uncle Sam’s coffers. Don’t increase your facility attractiveness to those who are looking for additional targets. By reviewing all payers, facilities set the precedent that increased reimbursement from CMS is not the only goal of a CDI program.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.

Radio Recap: Brundage discusses denials and physicians communication

ACDIS radio

ACDIS radio

Editor’s Note: Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group, LLC, in Redington Beach, Florida, presented on the January 11, 2017, installment of ACDIS Radio. The title of the program was “Denials and effective physician communication.” This Q&A was developed from conversations during that session. Should you have any questions regarding the material, please reach out to Brundage at DrBrundage@gmail.com.

Q: Have you encountered denials based on “Late Entry” where CDI query response was received after discharge?

A: This is a technique by the auditor to deny a reasonable diagnosis. The CDI team can query the physician up to the time of the final coding. Getting the query response and therefore clarification of the documentation and/or diagnosis in the official medical record allows the diagnosis to be coded and included in the final coded record. This should be accomplished no later than 30 days post-discharge.

Q: There are many primary care physicians who round in hospitals and flat out say that they don’t care about CDI, they’re not interested, or they refuse to hear education. How do we get through to them?

A: Leverage the influence of your physician advisor and/or chief medical officer to encourage them and share the value of CDI efforts with the rest of the medical staff. This helps both the facility and the physicians with value based care, length of stay (LOS) metrics, cost per case, case mix index, as well as CC/MCC capture and DRG shifts. Improving these aspects, in turn, help the physician in optimizing severity of illness (SOI) and risk of mortality (ROM) metrics. CDI also helps with the various measures included in CMS’ value based purchasing. Physicians who have managed Medicare patients (we all do at this point), benefit from record reviews focused on specificity related to the capture of diagnoses for hierarchical condition categories(HCC) as well.

Q: Can the CDI team do anything to help prevent short-stay denials?

A: Ask the medical director to review the chart of the denied claim to determine if the medical necessity of inpatient admission was met. If the medical director or CDI physician advisor believes medical necessity was met, have him or her reach out to the auditor over the phone for a peer-to-peer conversation before drafting an appeal letter. We get 89% of soft denials approved at the peer-to-peer level, but this number falls off dramatically if you allow these to become full denials that require an appeal letter. Your physician advisor can call and get these overturned with a collegial conversation much easier than a letter can.

Q: Do you have any recommendations on appealing a denied diagnosis due to clinical indicators, but in the discharge summary it states “possible” or “probable” and treatment was the focus of diagnosis?

A: Review for the clinical criteria to support the diagnosis documented in the medical record. Remember the CMS 72-hour payment window allows 72 hours of outpatient data to support your inpatient diagnosis. For example, the emergency department (ED) (an outpatient setting) documentation may support the inpatient diagnosis made at the time of admission. Fight denials of conditions that were present in the ED, but improved at the time of admission. These are valid diagnoses according to the CMS 72-hour payment window.

In addition, review the record to see if the following conditions for a secondary diagnosis were met:

  • Clinically evaluated
  • Therapeutically treated
  • Necessitated a diagnostic test or procedure
  • Increased length of stay (LOS)
  • Increased nursing care or monitoring

 

Guest post: Querying for clinical validity

by Erica E. Remer, MD, FACEP, CCDS

Some clinicians may interpret a query as an affront to their clinical judgment. This is not your intent. You are trying to determine whether a condition was present and whether it should compliantly be coded or not.

Here is an example of how a coder would provide the clinical indicators in the affirmative for the clinician to answer the query in regards to an intimated diagnosis:

Dear Dr. So and So,

The SCr was 3.4 and two days ago it was 1.4. You documented “renal dysfunction likely due to contrast.” Is there a diagnosis that corresponds to this?

You can also provide the physician with the documented diagnosis and the clinical indicators which make you skeptical:

Dear Dr. So and So,

You documented that this patient had pneumonia in the history and physical assessment. Over the course of the next three days, the repeat chest x-rays were read by the radiologists as “no infiltrate,” the sputum and blood cultures did not grow any organism out, and antibiotics were discontinued. However, the impression list continues to list “pneumonia.” Based on this information, please confirm the patient’s condition and your medical decision making, clinical support for the diagnosis in the medical record. If pneumonia was ruled out, please amend the assessment and plan, diagnosis list.

If a physician advisor supports the coding and CDI departments involve him or her in the process. The physician advisor can help create internal clinical guidelines to help providers ward off CVDs by standardizing criteria.

Make sure your providers see coders and CDI professionals as an ally, not an adversary, and that goal of CDI efforts is to protect both the physician and the facility from unnecessary denials.

Become educated

The last step is education—both for the CDI staff and for the physician.

Physicians often don’t know about clinical validations denials. When they occur, share them with providers. Point out what could have prevented them. Reinforce the good habit of documenting their thought process and explaining why they are doing what they are doing to and for the patient. Don’t accept responses to queries with only diagnoses and no clinical evidence supporting them.

Educate CDI and coding teams. If you have regular staff meetings, you can discuss topics which seem to be eliciting clinical validation denials. Changing clinical criteria may herald impending denials. Crowdsource best approaches to specific clinicians and specific conditions. Have joint discussions between coders and the CDI staff.

Clinical validation denials require time, energy, and resources to revisit patient encounters coded in the past. Concurrent clinical validation practices can prevent future denials by shoring up clinical support of valid diagnoses and eliminating others. An ounce of prevention is worth a pound of cure.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com.