This article is published in collaboration with MARSI.
Insurance denials can severely affect a facility’s revenue cycle. A successful appeal often requires a concerted effort between clinical and coding professionals, who often speak different languages in terms of interpreting documentation and applying guidelines.
Payers often have their own way of looking at things, which frequently differs from the facility’s viewpoint. To the facility, the importance of quickly identifying severe conditions such as sepsis or organ failure and initiating appropriate care is paramount. To the payer, having the luxury of looking at the case after the fact, there is often an expectation that every patient presentation should be a textbook one, in which the patient clearly had the condition for which they were treated. This includes meeting the expected diagnostic criteria and receiving the expected treatment without any other possible clinical scenario.
Health information (HI) professionals know there are many gray areas in diagnosing a condition, and denials are often fueled by these areas.
Exacerbating this issue is that many coding professionals are not clinically trained and may not be experienced with the payers’ expectations as these may differ. Clinicians are frequently unaware of coding issues and often use a set of clinical criteria to establish a diagnosis that differs from the set preferred by the payer. For example, this can occur when a provider uses sepsis 2 guidelines rather than sepsis 3 guidelines, but the facility has a contract with the payer stating the latter will be used to establish a diagnosis of sepsis.
Below are three case studies of denials to demonstrate how coding professionals can help prevent similar denials, or at least make the appeals process less time-consuming and expensive.
Case #1: Link Symptoms to the Condition
The patient was a direct admit from a wound care center. He had diabetic osteomyelitis of the left foot associated with skin and soft tissue infection of the calf. The patient has a history of systolic congestive heart failure (CHF) for which he takes Bumex 2mg twice a day. His proBNP was elevated (3780 pg/mL) and he was in atrial fibrillation. The cardiology consultant diagnosed acute-on-chronic CHF and the patient was given one dose of IV Lasix. The patient was not on home-based oxygen, but did require two liters prior to the IV Lasix.
The payer denied coverage of the acute component of CHF, citing a lack of symptoms. Further review found no other explanation for the oxygen requirement and an audit specialistargued this was the evidence of acute heart failure, along with the elevated proBNP, and the response to IV Lasix. The payer agreed and reversed their initial decision.
A denial such as this can be prevented if the coding professional recognizes that the provider’s documentation does not clearly link any particular symptom to the documented condition. A query could then be generated and the response made ready in the event the payer requests the record for review. This could also be handled with a clinical validation query, depending on the policies of the facility.
Case #2: Know the Clinical Criteria
The patient was brought to the emergency department (ED) by paramedics after a friend found him in bed confused and with perceived respiratory distress. He had a fever of 101 degrees Fahrenheit, was confused, and had an oxygen saturation of 88 percent on room air followed by 95 percent on four liters oxygen via nasal cannula. Symptoms included shortness of breath, tachypnea (22), wheezing, and scattered rhonchi. Venous blood gas (VBG) results demonstrated alkalosis. He was admitted with diagnoses of pneumonia, acute hypoxic respiratory failure, and more. The final diagnoses on the discharge summary included pneumonia and respiratory failure, and both were listed as chronic conditions.
The payer denied coverage for the diagnosis of acute hypoxic respiratory failure on clinical grounds, suggesting that the pneumonia should be re-sequenced as the principal diagnosis (PDX), and the respiratory failure removed entirely. The record was reviewed and an appeal submitted based on the demonstrated P/F ratios of 270 on room air and 222 on four liters O2 along with the VBG results. The payer then overturned the denial.
Denials like this are difficult to prevent—though easy to appeal—since the clinical indicators were present and the documentation was clear. It seems the payer either misinterpreted or misrepresented the documentation in the record. This case serves as a reminder that not all denials are avoidable. That said, the coding professional should be aware of the clinical criteria for acute respiratory failure.
Case #3: Clarify Documentation Discrepancies
A patient presented to the ED with respiratory distress on bilevel positive airway pressure (BIPAP). She was quickly weaned to 5 liters via nasal canula (NC). Her home oxygen baseline was 2 liters per NC. The patient was admitted and the documentation in the health record noted chronic obstructive pulmonary disease (COPD) exacerbation and acute on chronic respiratory failure. At discharge, however, chronic respiratory failure was documented.
In this scenario, a coding professional may simply assume the acute element of the respiratory failure had resolved. The payer interpreted this as the acute respiratory failure being ruled out and thought the COPD exacerbation should be sequenced as the principal diagnosis followed by chronic respiratory failure as a secondary diagnosis.
After record review, the facility issued a query to clarify the final diagnosis for this encounter. The provider confirmed acute on chronic respiratory failure as a valid diagnosis and the denial was overturned. This type of denial may have been prevented by clarifying the documentation gap before submitting the claim.
Coding professionals can play an instrumental role in preventing denials and reducing the burden of the appeals process. The key is to identify gaps in the documentation and utilize the query process to close those gaps prior to submitting the claim to the payer. Many facilities find that education-focused, pre-bill audits and/or a second-level review process are an effective way to identify these cases and clarify the documentation as needed. The information obtained from these audits may be used to teach their coding professionals what to look for and how to successfully clarify documentation issues.
Aaron Drummond, CCS, is a denials specialist at Medical Audit Resource Services (MARSI).
MARSI has a team of coding and clinical experts who audit, educate and support clients’ documentation, coding, medical necessity, and admission status including insurance denials.