Are All Coding Denials Preventable?

Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.


By Elena Miller, MPH, RHIA, CCS

 

According to a survey conducted by the Advisory Board in 2017, the number of denials written off as uncollectable increased by 90 percent compared to six years prior. The benchmarks show that a median 350-bed hospital would have lost $3.5 million to increased denial write-offs over a period of four years. There have been many articles and blog posts written stating that denials volume is increasing and healthcare providers need to be proactive in preventing denials. One article stated that 90 percent of denials are preventable—speaking in terms of all denials, not just those related to coding.

There is some misconception when it comes to coding denials. Many may think that a coding denial is the result of a coder assigning a code for a condition that wasn’t documented in the record. Does this happen? Yes. Is this the source of most coding denials? No. Coding-related denials are received for a variety of reasons, including diagnosis and procedure coding, clinical validation, missing documentation (record requests), and discharge disposition codes.

Diagnosis, Procedure Disposition Code, and Missing Documentation Denials

How can these types of denials be prevented? Through ongoing internal coding quality audits and ensuring that coders are up to date with AHA Coding Clinic advice. Validate that release of information templates used to fulfill payor requests contain all of the necessary documents. Check with the appeals team to find out if they are commonly seeing denials due to missing body mass index or rehab documentation. That would be an indicator that a certain document is not being included. Confirm that processes are in place to ensure that the discharge disposition is accurately documented and updated if the plan changes post-discharge.

When can these types of denials not be prevented?

  • Just like hospitals, payors have a difficult time finding quality auditors. There are times when the denial determination conflicts with Coding Clinic advice. For example, the payor has determined that dehydration should be assigned as the principal diagnosis when a patient is admitted with acute renal failure due to dehydration. There is longstanding Coding Clinic advice on this topic. These types of findings make it appear as if the reviewer lacks coding experience.
  • There are times when denial determinations are based on outdated Coding Clinic advice. For example, the sequencing of COPD and pneumonia. Not all reviewers have kept up with the change in guidance. A denial determination may be received that is in conflict with the instruction that was in effect at the time of discharge.
  • A misinterpretation of the operative report by an auditor may result in a procedure code denial.
  • Some denials simply come down to a matter of opinion. For example, two conditions equally meeting the definition of a principal diagnosis.
Clinical Validation Denials

First and foremost, clinical validation coding denials did not go away with the “code assignment and clinical criteria” guideline.

How can these types of denials be prevented? By working with the medical staff to develop clinical criteria to assist in diagnosing patients. Empowering the coding and clinical documentation improvement staff to query when a documented diagnosis does not appear to meet the determined clinical criteria.

When can these types of denials not be prevented?

  • Some payors may have established their own clinical criteria. Where one payor may deny a diagnosis, another may not based on the same clinical indicators documented in the record.
  • A reviewer may only be looking for certain clinical indicators and overlook other supporting indicators that were documented in the record. This could result in a finding stating that there is lack of clinical evidence.
  • A coder may have sent a clinical validation query to a provider. If the physician confirms the diagnosis, a coder cannot determine that the diagnosis should not be coded. Even with the physician’s confirmation, the diagnosis could still be denied.

A large volume of denials received could be prevented, either by the provider or by the payor, and work needs to be done to reduce that number. As mentioned previously, the volume of denials appears to be steadily increasing. Providers need to remain persistent in fighting denials, regardless of its preventability. Hopefully, those outside of coding will understand that a coding denial does not automatically mean that Coding made a mistake or that there was even a mistake made. There are many coding denials that just can’t be prevented.

 

Elena Miller is the director of coding audit and education at a healthcare system.

1 Comment

  1. The timing of your article is priceless. Thank you for spreading the knowledge when it comes to coding denials and auditing practices to validate clinical diagnoses.

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