CDI in Denials Management

By Tammy Combs, RN, MSN, CDIP, CCS, CCDS

There is a saying that my husband tells me all the time: “If you want to accomplish something as quickly as possible, take your time and do it right the first time.” This is something I have thought of many times when working in clinical documentation improvement (CDI), especially when dealing with denied claims. The importance of high quality documentation has come to the attention of denials management teams. For this reason, organizations are beginning to incorporate CDI professionals into the denials process. CDI professionals can serve as subject matter experts (SMEs) when the denials occur due to a lack of documentation or clinical evidence.

The involvement of CDI professionals in the denials process can assist denials specialists in identifying appeals opportunities. CDI professionals can also incorporate the reasons for denials into their daily health record documentation reviews. This can in turn assist in reducing the number of denials by getting the documentation right the first time.

CDI professionals are now looking for information to guide them in the denials process. The AHIMA CDI Taskforce, along with other CDI professional volunteers, is working on a Denials Management Toolkit, to be published the beginning of 2018. Below are some of the key topics addressed in the toolkit.

Types of Medicare claim reviews

  • There are three basic reviews that are performed by Medicare. These include automated, non-medical record, and medical record reviews. Automated reviews are considered technical denials, they review electronic information. Non-medical record reviews are done on the information that is included on a claim. A medical record review occurs when the health record is reviewed.

How to determine if an appeal is warranted

  • When reviewing a denial to determine if an appeal should be made it is important to first review the timelines. Some organizations fail to submit an appeal within the allotted time, which results in an allowance of the denial to stand. The next step is to collect evidence from the heath record to determine if it supports the denial or the original claim. This is when a SME may be brought to perform a second level review of the information, to determine if an appeal is needed.

Creating a concrete appeal letter

  • It is vital to develop a well thought out appeal letter. A denials letter should include patient identification and a restatement of the reason for the denial. Then a statement should be provided to explain the reason why the organization believes the denial is inaccurate. Then the letter can document the evidence from the health record to support the statement for appeal. The letter would then conclude with the requested outcome from the appeal.

The Medicare appeal process

  • The Medicare appeals process includes five levels of appeals. The first level is a redetermination by a Medicare Administrative Contractor (MAC). The second level is reconsideration by a Qualified Independent Contractor (QIC). The third level is a hearing by an Administrative Law Judge (ALJ). The fourth level is a review by a Medicare Appeals Council. Then the fifth level is a judicial review in federal district court.

Tracking and trending denials data

  • Tracking and trending data can provide useful information that can be used to identify education opportunities and process improvements, to help eliminate similar denials in the future.

Denials prevention

  • Implementing CDI programs is one key element to preventing denials that are due to missing documentation and/or clinical evidence. The information gained from tracking denials can be vital in denials prevention. When you know why something is happening then changes can be implemented to prevent it from occurring in the future.

Are any of you being pulled into the denials process? If so, it would be great if you could share your experiences.

 

Tammy Combs, RN, MSN, CDIP, CCS, CCDS, is director and lead nurse planner of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members, the media, and outside organizations on clinical documentation improvement (CDI) practice issues. Combs authors material and provides support for AHIMA’s online CDI education platforms. She also serves as faculty for the AHIMA CDI Academies and CDIP Exam Preps, and is a technical advisor for AHIMA on CDI publications.

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