Management and Appeal Strategies for DRG Change Recommendations

Suzanne Drake, RHIT, CCS, who has been writing appeal letters since 1995, reviewed some very important steps for a successful appeals management process, beginning with following the paper trail, at Sunday’s 2017 AHIMA Clinical Coding Meeting. Drake, with Bon Secours Health System, based in Virginia, presented to a packed room.

Identification of the agency letter access point(s) is a key first step, Drake said. Any delays in appeal processing can turn into missed deadlines and lost money for the facility. If the facility has a single access point for all letters, “try to make it a position-specific process and not a person-specific process,” Drake recommended. A designated person trained on which letters should go to which departments can prevent lost opportunities to file an appeal by ensuring timely delivery of agency letters to the appropriate staff.

The second step is establishing an effective correspondence process. This can be done by defining who is responsible for the review and appeal process for the different types of denials. A facility can do this by developing a team where there is a well-defined understanding of who those individuals are and what they are responsible for. Additionally, a facility needs to identify what tool(s) will be used to manage the process, Drake said. Some facilities use the Recovery Audit Contractor (RAC) tracking tool they already have in place for their non-RAC audits.

After a process has been defined and established, the next step is to implement the appeals process itself. Drake stated that it is not enough to just read the reason for the denial. Be sure to read the entire letter to identify the timeframe for the appeal, where the appeal should be directed, and how it should be appealed. The agency letter should also include how to proceed if the recommendation is accepted by the facility. If the facility agrees with the decision, do not waste time on a fruitless effort, Drake said. It is also important that all required forms are completed when responding to the recommendation.

As the response to the agency is being developed, it is important to “speak in their own language,” according to Drake. Always use the same terminology that is included in the agency letter. For example, some agencies will state that you can apply for reconsideration while others may state that you can file an appeal.

“All DRG change recommendations are not created equal,” Drake said. The facility needs to determine the core reason for the DRG change recommendation. Most agency letters provide general change recommendations, such as insufficient documentation, incorrect procedure, or clinical denials. Ensure that the exact reason for the recommendation can be determined.

When preparing the appeal/response, always use and cite official and reliable coding and reporting resources such as the American Hospital Association’s Coding Clinic®, the Centers for Medicare and Medicaid Services’ (CMS) Official Guidelines for Coding and Reporting, the CMS website, and the US National Library of Medicine. Use of all available resources can help successfully appeal, even to the highest level.

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