Make Denials Work for You

1
Make Denials Work for You

• Margi Brown, RHIA, CCS, CCS-P, CPC, CCDS
• AHIMA Certified ICD-10 Trainer
• Independent Health Information Management
  Consultant

2
Discussion Points

• Denials working for you - Really?
• Start backwards
• Our reality
• The Whys
• H.I.M. the buck stops here
• The goal 0 or minimal
• Work smarter, not harder
• Inventory of who does what
• Tap into existing resources
• Coordination of billing and efforts
• Professional E/M leveling
• Surgical procedures
• CDI program
• Too aggressive?
• Too passive?
• Oversight of the entire process

3
Objectives

• After this session, the participation should be
  able to
• Initiate a baseline for all denials and
  categorize the patterns/trends
• Differentiate the types of denials for timely
  assignment to as to who does what
• Substantiate the missing pieces of denials
  involving coding and/or medical necessity
• Understand the different focus points from the
  different perspectives
• Hone in on (some) core content for those hot
  topic denials
• Define next steps moving forward in the process

4
For more information visit AHAs RACTrac
websitehttp//www.aha.org/aha/issues/RAC/ractrac.
html
The next few slides are directly from AHA RACTrac
Great resource Did your hospital join? Do
you receive this information?
5
AHA RACTrac Findings 1Q 2011

• The majority of medical necessity denials
  reported were for 1-day stays where the care was
  found to have been provided in the wrong setting,
  not because the care medically unnecessary.
• Hospital respondents reported Syncope Collapse
  as the top MS-DRG denied by RACs for both medical
  necessity denials and incorrect coding denials.
• 57 of all participating hospitals with RAC
  activity reported receiving at least one
  underpayment determination.
• Hospitals reported appealing nearly one in four
  RAC denials, with a 71 success rate in the
  appeals process

6
AHA RACTrac Findings 1Q 2011

• 75 of participating hospitals reported that RAC
  impacted their organization this quarter and 49
  reported increased administrative costs.
• 55 of respondents indicated they have yet to
  receive any education related to avoiding payment
  errors from CMS or its contractors.
• 52 of hospital respondents reported problems
  with reconciling RAC recoupments and untimely RAC
  correspondence.

7
Region C StatsAmong Reporting Hospitals

• Dollar value of automated and complex denials
  (activity through)
• 1Q2011 51.7M
• 4Q2010 33.7M
• 3Q2010 20.8M
• Average dollar amount of automated and complex
  denials
• Automated 328
• Complex 5,416

• Top reasons for automated denials - of errors
• 68 outpatient billing
• 12 outpatient coding
• 4 inpatient coding (MS-DRG)
• 8 duplicate payment
• 8 all other
• Reasons for complex denials
• 34 incorrect DRG or other coding
• 59 medical necessity
• 5 other
• 2 insufficient or no documentation in the
  medical record

8
It Is a Full Circle Process

• Use a comprehensive communication process from
  front to back and visa versa
• Include all other key areas
• Wrap any retrospective activities including
  audit results into the CDI program for a full
  circle approach

Communication front to back and in-between
9
Bottom Line

• Hospitals as well as each physician need the most
  accurate and specific documentation that
  translates into correct and compliant coding to
  reflect the true complexity of care and severity
  of illness of their patients.
• Documentation Code(s)
• Solid
• Consistent
• Supported
• Common (and agreed upon) goal?

10
Communication Disconnects
Clinical Patient Care
Economic Coding Reimbursement
11
Inventory the Denials

• Not just RAC denials
• Categorize all
• Volume? Trends? Patterns?
• Status Inpatient, outpatient, physician all
  of the above?
• What bucket? Coding? Process? Medical
  necessity? Admission status case management?
  Quality? All of the above?
• Medical vs. surgical?
• Is it documentation or a clinical closeness
  question?
• Is this a high risk or high change topic?
• How does it fit with the clinical picture of the
  patient?

12
Back to Basics
How many people are already in the chart? For
what purposes? Steamline Communication AND
process - flow Coordination of billing
Medical Record
13
Documentation Basics

• Just a few starting points
• The medical record can be compared to a story
  book of this patient.
• Does the documentation paint the complete
  picture of the patient?
• Any documentation - the good, the bad and the
  ugly does affect ALL the hospital, the
  provider, the payor - and specifically the
  patient. This is the driver of the trickle down
  effect.
• The basics of just understanding the basic
  documentation requirements are critical.
  Customize your approach.

14
Coders Role

• As a basic awareness
• Coders are required to code to the highest degree
  of specificity, but the quality physician
  documentation HAS to be there in the first place.
  
• Coders are bound by many rules/guidelines for
  application of the translation process of
  narratives to numerical codes, which generates
  the bill.
• Coders are not licensed to make the diagnoses, so
  if it is not stated, it cannot be coded!
• Determine your place in the overall setting.

15
Joint Effort

• Joint effort of documentation and coding
• Finally, you should keep in mind that achieving
  complete and accurate documentation, code
  assignment, and reporting of diagnoses and
  procedures requires a joint effort between the
  healthcare provider and the coder.
• Source MLN Matters Number MM5499 Related
• Change Request Number 5499, 091107
• update and Transmittal 289 071707 update

16
The Plan

• Define the issue(s) and then the fit(s)

• Targets
• Documentation basics
• Pdx assignment
• Certain diagnoses, procedures, etc.
• Roles of those involved
• Areas in revenue cycle

17
Coordination of Billing

• Facility and/or professional coding/billing How
  can you tap into the professional/provider world
  to assist in the facility/hospital and visa
  versa?
• Just a few notes
• Hospital coding guidelines are different in some
  areas as compared to the physician area.
• Hospital inpatient and outpatient have
  differences.
• Medical necessity requirements are the same.
• Good documentation is still necessary for ALL!

18
Data Sources

• For both hospitals and physicians
  Documentation leads to identification of
  diagnoses and procedures
• The bills and format are different from the
  hospital to the physician DRG, APC, or group
  type of payment, vs. line item, of charges,
  etc.
• ICD codes are the diagnoses medical necessity
• CPT/HCPCS codes are the procedures and services
  performed (by the provider and outpatient
  facility)
• The codes may not be exactly the same for the
  diagnoses from the hospital due to the
  differences in the coding guidelines.
• BUT, they need to be at least in the same
  ballpark
• Surgical cases for CPT/HCPCS (modifiers)
• The physician codes will also show severity.

19
OBS vs. Inpatient STATUS

• Observation
• Initial OBS day (3/3) 99218 99220
• Same DOS for admit/disch (3/3) 99234-99236
• Disch 99217
• Extra days (2/3) 99211-99215 (per CMS)

• Inpatient
• Admit, HP (3/3)
• 99221-99223
• Same DOS for admit/disch (3/3) 99234-99236
• Subsequent day (2/3) 99231-99233
• Disch 99238 - lt 30 minutes 99239 - gt 30
  minutes

Admit order AND medical necessity
20
E/M Complexity of Medical Decision Making
Determined by (1) Number of diagnoses or
treatment options, (2) Amount and/or complexity
of data reviewed, and (3) Risks of complications
and/or morbidity or mortality
1. Number of Diagnoses or Treatment Options
D
C
B
A
Number
Points
Results
Problem(s) Status
Self limited/minor
1
max2
Established problem to examiner stable/improved
1
Established problem to examiner worsening
2
New problem to examiner w/no additional workup
planned
max1
3
New problem to examiner w/additional workup
planned
4
TOTAL
21
CDI Frame Work Program

• Set your key goals involving
• Complete clinical documentation
• Coding quality
• Medical necessity
• RAC and denial vulnerabilities
• Set the parameters
• Executive support
• Teeth enforcement that works in your
  facility

• Set your table
• Who is involved
• Who is the key point person
• Determine the level of involvement,
  responsibility, and authority
• Map the process
• Agree on the roadmap
• Oversight
• Monitor for tone
• Too aggressive?
• Too passive?

22
Measure and Analyze
Staff with Medical Leadership, and ALL
Initial Analysis
Further Analysis Quantification
Share reports, findings, patterns, trends seek
root cause(s). Measure rates Denial, appeal,
success
Individual by physicians, group, specialty,
coder, DRG, diagnosis, procedure, certain areas
of facility, etc
Develop improvement plans, implement, monitor,
feedback, etc.
23
Stop Gaps

• After your basic homework is done, determine the
  game plan and start with those specific areas
• Use the combined approach with development of
  common documentation scenarios, building of
  templates, queries, and/or focus additional
  support where needed
• Does this cover only inpatient cases or all types
  such as outpatient and/or physician areas?
• Budget
• Start small and plan to expand

24
The Due To, LINK, and Name it
Admission status medical necessity
25
Name IT Etc.

• Label tag
• Acuity
• Severity
• Significance / Relevance
• Connection
• Contradiction
• Supportive
• CLEAR
• Outpatient
• Symptom Rule out

Case management, (IS/SI), core measures, Quality,
etc.
26
Assign Rank as the 1 Driver

• The principal diagnosis (PDx) is the initial
  driver to the (one) MDC.
• Then driving on to the most specific DRG/MS-DRG
• With of course several factors involved and
  according to the guidelines (several)
• Source ICD-9-CM Official Guidelines for Coding
  and Reporting, Section II

Selection of the inpatient admission PDx
Defined in the UHDDS as "that condition
established after study to be chiefly responsible
for occasioning the admission of the patient to
the hospital for care. Circumstances of
admission always govern the selection of the
PDx. Meet the definition of the PDx. Also,
diagnostic work up and/or therapy provided
weighs in.
27
Inpatient MS-DRG Flow and Positioning
28
Qualifying the Diagnosis

• Diagnosis Status
• Differential diagnosis
• Ruled-out vs. ruled-in
• Rule-out, possible, probable
• When documented? (Discharge documentation)
• Resolved
• Natural progression acute, chronic, acute on
  chronic, acute vs. chronic, etc.
• Carried through the chart
• Documented consistently
• Does it make sense?

• Was it treated?
• Was it only mentioned once?
• Were the lab values supportive?
• Minimal values
• Did the physician validate?
• Clinical significance
• Re-confirm the pathology
• Findings from consultant(s)
• insufficiency vs. failure
• Did it meet the severity level?
• Example malnutrition mild, moderate, severe,
  unspecified

29
Disease Management and Coding

• New diagnosis
• Acute phase in a chronic, long term disease
• History of
• Cancer
• Another condition related to that condition
• Circumstances of admission

• Disease process with lots of manifestations and
  coding rules
• Code first - sequencing
• Diabetes
• Called something, but coded something else
• Coagulopathy
• Coagulopathy in a patient on Coumadin

30
Outpatient Documentation

• Order
• Progress notes
• Operative report
• Provider reports
• Pathology
• Lab, radiology, other services
• Reports from outside facility

• Process?
• Indication for test
• Written narrative diagnosis or code
• POS point of service
• Time frames
• Documentation to final billing
• Service provided
• Status elective or urgent, etc.
• Weekends
• Medical necessity and coding
• Facility and professional

31
Medical (Inpatient) Targets

• Just a few
• Unrelated procedures to the the principal
  diagnosis
• High-weighted and/or high-dollar (charges) with
  short length of stays
• High volume

• Those debatable diagnoses
• Sepsis
• Renal failure
• Respiratory failure High volume
• Multiple principal diagnosis assignment
  possibilities
• HACs
• Add the double check safety net
• CDI
• Current denial areas
• Coding issues
• Internal external review
• National hot spots

32
Procedures / Surgeries

• It is what it is, but .
• Where are those focal points that may need some
  additional help while the patient is still in
  house?
• and why??

• Just a few suggestions
• Excisional debridement
• Adhesiolysis
• Pleurodesis
• Transbronchial lung biopsy - TBLB
• Mechanical vent
• 96 hours

33
Excisional Debridement

• Excisional Debridements
• Description of the wound(s)
• Depth and definitions
• Procedure explained
• Instruments, methods, etc.
• Location of the procedure
• OR
• Bedside
• Wound Care
• Patients clinical picture
• Current
• Past and relevant
• Inpatient vs. outpatient / physician
• ICD-9-CM vs. CPT

Non-excisional Skin Skin subQ Muscle/tendon Bon
e Other
34
Debridement Denial Examples
86.22 (excisional debridement) was changed to
86.28 (non-excisional).

• Patient 1
• The patient was taken to the OR and using a 10
  blade, necrotic tissue was EXCISED from the left
  and right ulcerations, partial thickness level
  ".
• Very large ulceration to the left medial ankle
  area, measuring approx 11.4 cm x 6.5 cm, depth of
  0.4 cm, mostly granulated tissue, foul odor, with
  one maggot found.... the right is pale looking,
  with minimal granulation, measuring approx 3.6 cm
  x 3.5 cm, with a depth of 0.3.

• Patient 2
• "debridement of the hyperkeratotic skin and wound
  eschar using a tweezers/scalpel/scissors".
• the sharp debridement of the yellow slough
  film that is overlying in the wound base,.
• Patient 3
• "Tx-Received wound dressing and sharp
  debridement, 100 removal of black eschar", etc.
• Day 1 post debridement. This 2x1.5 cm with
  eschar reddened area - not as "angry" as
  yesterday,

35
Adhesions

• When obstruction is present or adhesions are
  cause of pain or dysfunction and lysis is a major
  procedure
• Obstruction not present
• Strong band of adhesions prevents surgeon from
  access to the organ being removed
• Requires lysis before operation can proceed
• Significance must be documented by surgeon
• Source Coding Clinic 4th Q 1990

• When are adhesions significant enough to code
  additionally both the diagnosis and the
  procedure?

Documented how? Summary of findings in the OR
title in addition to body of the OR report.
Coordination of billing facility surgeon.
36
Procedures Surgical vs. Medical
Pleurodesis

• SURGICAL MS-DRGS
• Major chest procedures
• 163 (w MCC) rw 5.0828 to
• 165 rw 1.7758
• Mechanical Code 34.6
• Coding Clinic References
• 4Q2007, 1Q2007, 1Q1992, 2Q1989, May-June 1985

• MEDICAL MS-DRGs
• Chemical Code 34.92
• With cancer chemotherapy substance (add 99.25)
• Tetracycline (add 99.21)
• Ex pleural effusion as pdx - 186 188
• Rw 0.7678 1.5637

• (Relative weight difference of 1.008 3.5191)

37
Procedures Surgical vs. Medical
Lung Biopsy

• SURGICAL MS-DRGs
• Major chest procedures
• 163 - 165
• Open 33.28
• Other resp system OR procedures 166 (w MCC)
  168
• Rw 1.3008 3.7383
• Thoracoscopic 33.20
• Closed (NEC), endoscopic, Transbronchial lung
  biopsy, transbronchial needle aspiration of lung
  (TBNA) 33.27

• MEDICAL MS-DRGs
• Brush 33.24
• Closed / Percutaneous / needle 33.26
• Fine needle aspiration (FNA) of lung
• Transthoracic needle biopsy of lung (TTNB) 33.26

38
Transbronchial Lung Biopsy

• Documentation must specify the scope passed thru
  the bronchus and into the lung and actual lung
  tissue was obtained.
• AHA Coding Clinics
• 2Q2009
• 3Q2004
• 3Q1991

• The transbronchial biopsy procedure is performed
  using a tiny forceps passed through a channel of
  the bronchoscope into the lung.
• The forceps puncture the terminal bronchus, and
  samples of the peribronchial alveoli (lung
  tissue) are taken (4Q1992, pages 27-28).

39
Transbronchial Lung Biopsy

• Denial Issue TBLB
• Both the bronchoscopy with biopsy codes 33.24
  (bronchus) and 33.27 - transbronchial (lung)
  biopsy were coded and assigned to the surgical
  MS-DRG 166
• The TBLB code 33.27 was deleted with the
  reasoning that the path does not show any lung
  tissue and this code was not supported in the
  documentation.
• The MS-DRG was changed from
• 166 (other resp sys OR w MCC RW 3.7383, GMLOS
  9.5 days
• to
• 186 (Pleural effusion w MCC -
• RW 1.5637, GMLOS 5.3 days)
• (Difference rw 2.1746)

• The OR report states " endobronchial brushings
  were obtained from the right lower lobe, followed
  by transbronchial biopsies and bronchoalveolar
  lavage.
• Must define lobe
• Bronchus vs. lung
• Pathology
• Radiographic guidance
• Resources
• Form revision
• Impact
• Volume, dollars, risk factor

40
Time Based Services

• Vent Time of 96 hour threshold
• 96.72 gt 96 hours
• 96.71 lt 96 hours
• Infusion(s)
• Start AND stop time
• Modifiers
• Professional in the global surgical time period

• Evaluation and Management
• Leveling 3 key components versus time
• Critical care
• Only time based codes
• Default minimum?
• Status
• Observation
• 72 hour rule
• Billing coordination
• Resource OIG work plan

41
Acute Renal Failure Denial Examples

• Documentation is just not consistent or upheld
  through the record The progress notes may state
  acute renal failure, but it is not documented in
  the discharge summary and/or acute is checked
  on a query form (part of the perm record), but is
  still in question, clinically.
• No clear documentation of the patients
  "baseline", so the reviewer's impression of an
  increase of 50 of this baseline was assumed upon
  the creatinine level on admission.
• Contradictions of terms for the coder as well as
  the physicians involved, including ARF, AKI,
  insufficiency, failure, etc
• Based on different thresholds by the individual
  physician(s), group(s), etc.
• Standard definitions?
• NOTE Acute renal failure code 584.9
  downgraded status from MCC to CC as of 10-1-2010

42
IS It Really Renal Failure?

• Insufficiency, failure, or AKI?
• Which standard definition?
• RIFLE or AKIN criteria
• Others
• Severity driver
• (CC? prior to 10/01/10 was a MCC)
• Various clinical presentations
• Acute, chronic, or acute on chronic
• With dehydration
• Asymptomatic
• Several etiologies
• Coding Guidelines

43
Clinical Criteria of Acute Kidney Injury

• Two prevailing definitions of AKI/ARF exist, as
  outlined in the following table

http//ccforum.com/content/11/2/R31 AKIN
http//ccforum.com/content/8/4/R204 -
ADQIG Note AKIN criteria requires 2 creatinine
levels 48 hours apart and presumes that fluid
resuscitation has occurred. Neither require that
the patient receives dialysis. Note Most
nephrologists equate RISK in RIFLE to be Acute
Kidney Injury, even if it is not
labeled as such. Further clarification from
these authors is forthcoming.
44
Or, What Is It?

• Acute Kidney Injury
• a common clinical syndrome defined as a sudden
  onset of reduced kidney function manifested by
  increased serum creatinine or a reduction in
  urine output.
• It is NOT the underlying renal pathology
• Currently a preferred term and synonym for acute
  renal failure or acute kidney failure.
• Some physicians may not agree
• Resource Srisawat N., Hoste, E., Kellum, JA.
  Modern Classification of Acute Kidney Injury.
• Blood Purification 201029300307.
• Available for free at http//tinyurl.com/AKI-201
  0-Review

• Acute Kidney Insufficiency
• The same definition as acute kidney injury, yet
  the rise of creatinine or fall of urine output
  fails to meet the acute kidney injury criteria
• Azotemia
• a medical condition characterized by abnormally
  high levels of nitrogen-containing compounds,
  such as urea (BUN) , creatinine, various body
  waste compounds, and other nitrogen-rich
  compounds in the blood.
• Uremia
• A term used to loosely describe the illness
  accompanying kidney failure, in particular the
  nitrogenous waste products associated with the
  failure of this organ

45
AKI Criteria

• Diagnostic criteria for acute kidney injury
• An abrupt (within 48 hours) reduction in kidney
  function currently defined as an absolute
  increase in serum creatinine of more than or
  equal to 0.3 mg/dl ( 26.4 µmol/l), a percentage
  increase in serum creatinine of more than or
  equal to 50 (1.5-fold from baseline), or a
  reduction in urine output (documented oliguria of
  less than 0.5 ml/kg per hour for more than six
  hours).
• The above criteria include both an absolute and a
  percentage change in creatinine to accommodate
  variations related to age, gender, and body mass
  index and to reduce the need for a baseline
  creatinine but do require at least two creatinine
  values within 48 hours. The urine output
  criterion was included based on the predictive
  importance of this measure but with the awareness
  that urine outputs may not be measured routinely
  in non-intensive care unit settings. It is
  assumed that the diagnosis based on the urine
  output criterion alone will require exclusion of
  urinary tract obstructions that reduce urine
  output or of other easily reversible causes of
  reduced urine output.
• The above criteria should be used in the context
  of the clinical presentation and following
  adequate fluid resuscitation when applicable.
  Note Many acute kidney diseases exist, and some
  (but not all) of them may result in acute kidney
  injury (AKI). Because diagnostic criteria are not
  documented, some cases of AKI may not be
  diagnosed. Furthermore, AKI may be superimposed
  on or lead to chronic kidney disease.
• Source Mehta et al. Critical Care 2007 11R31
    doi10.1186/cc5713

46
Terms of Malnutrition

• Malnutrition (calorie) 263.9
• Degree
• First 263.1
• Second 263.0
• Third 262
• Mild (protein) 263.1
• Moderate (protein) 263.0
• Severe 261
• Protein-calorie 262
• Malignant 260
• Mild (protein) 263.1
• Moderate (protein) 263.0
• Protein 260
• Protein-calorie 263.9
• Mild 263.1
• Moderate 263.0
• Severe 262
• Specified type NEC 263.8
• Severe 261

• Weights
• MCC 260, 261, 262
• CC 263.2, 263.8, 263.9
• Terms
• CC 3Q9009, page 6
• Code 260, Kwashiorkor, is not appropriate since
  the provider did not specifically document this
  condition. Kwashiorkor syndrome is a condition
  that is caused by severe protein deficiency that
  is usually seen in some underdeveloped areas in
  Africa and Central America however it is
  extremely rare in the US.
• The National Center for Health Statistics (NCHS)
  is considering a proposal to revise the index
  entries under mid and moderate protein
  malnutrition in order to provide a clearer
  direction to the coder.

47
Malnutrition
Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition Values Commonly Used to Grade the Severity of Protein-Energy Malnutrition
Measurement Normal Mild Malnutrition Moderate Malnutrition Severe Malnutrition
Normal weight () 90110 8590 7585 lt 75
Body mass index 1924 1818.9 1617.9 lt 16
Serum albumin (g/dL) 3.55.0 3.13.4 2.43.0 lt 2.4
Serum transferrin (mg/dL) 220400 201219 150200 lt 150
Total lymphocyte count (per mm3) 20003500 15011999 8001500 lt 800
Delayed hypersensitivity index 2 2 1 0
In the elderly, BMI lt 21 may increase mortality risk. In the elderly, BMI lt 21 may increase mortality risk. In the elderly, BMI lt 21 may increase mortality risk. In the elderly, BMI lt 21 may increase mortality risk. In the elderly, BMI lt 21 may increase mortality risk.
Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 lt 0.5 cm, 1 0.50.9 cm, 2 1.0 cm. Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 lt 0.5 cm, 1 0.50.9 cm, 2 1.0 cm. Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 lt 0.5 cm, 1 0.50.9 cm, 2 1.0 cm. Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 lt 0.5 cm, 1 0.50.9 cm, 2 1.0 cm. Delayed hypersensitivity index quantitates the amount of induration elicited by skin testing using a common antigen, such as those derived from Candida sp or Trichophyton sp. Induration grade 0 lt 0.5 cm, 1 0.50.9 cm, 2 1.0 cm.
Source http//www.merck.com/mmpe/sec01/ch002/ch00
2b.html
48
Discharge Documentation

• Discharge documentation Should
• Conclude what occasioned the admission and then
  what is the principal diagnosis -- after
  study
• Discuss the complexity of the patients illness
  (secondary diagnoses)
• Summarize the things that went wrong and the
  things that improved
• Be as specific as possible regarding pathogenesis
  of disease, the medical decision making, and
  other intangible thought processes
• Summarize the outcome
• List the post-hospital care to follow
• Tell the story of the hospital stay.
• Have no contradictions (Insufficiency, failure,
  distress, etc.) and specifically at the time
  of discharge what/which is it?
• Be consistent with the rest of the record, also
  not introduce new information unless as the
  result of recent test findings or more recent
  information.
• Be clear and concise - the discharge summary
  should not regurgitate the HP it should be
  what it is called - a summary on discharge
• Be TIMELY
• Be documented from one who took care of the
  patient (this can be a sticky subject)

49
Query Protocols

• Lack of accurate and complete documentation can
  result in the use of nonspecific and general
  codes, which can impact data integrity and
  reimbursement and present potential compliance
  risks.
• The strong purpose of a query is to assist in
  providing solid documentation of those unique
  clinical situations and the assurance that the
  documentation in the record supports the codes
  assigned.
• It is critical that the design of the queries and
  the query process be created and maintained with
  legal, regulatory, and ethical issues in mind.
• Set your infrastructure and policies for
  concurrent, retrospective, or post-bill queries.
  Make it a unified process.
• A multidisciplinary team should be involved in
  creation and evolution of the forms and process.
  Involve the physicians up front and by using
  their specific examples, pertinent to their
  specialty.
• Discuss and agree on the basic requirements
  permanent part of the chart, format, core
  content, language of the question, etc.

50
Query Language

• It is recommended that queries be written with
  precise language, identifying clinical
  indications from the health record and asking the
  provider to make a clinical interpretation of
  these facts based on his or her professional
  judgment of the case.
• Article citationAHIMA. "Managing an Effective
  Query Process" Journal of AHIMA 79, no.10
  (October 2008) 83-88.

• Clarify
• Validate
• Verify
• Conflicting diagnoses
• Significant finding
• Specify
• Complete
• Legible
• Cause and effect
• Due to
• Link
• Manifestation
• Underlying cause

51
Review and Appeal

• 5 point format
• REVIEW rationale behind the determination
• FIND the meat and potatoes of your argument
  that supports your position that the denial is
  incorrect and should be reversed.
• CITE official sources to support your position
  in addition to coding guidelines (CMS
  regulations, articles from Coding Clinic or CPT
  Assistant, textbooks, etc.)
• POINT OUT specific documentation to support codes
  and/or medical necessity. Paint the picture of
  the patient.
• SUMMARIZE your rationale in a positive manner and
  stay focused.

52
Respiratory Failure Denial Example

• Issue PDx was resequenced from acute
  respiratory failure 518.81 to AECOPD acute
  exacerbation of COPD 491.21 based on the fact
  that the patient is a smoker and the ABGs and
  the pulse- ox do not reflect this diagnosis.
• Rebuttal The physician clearly documented acute
  respiratory failure through the chart, as the
  reason for admission as well as the discharge
  summary stating the final diagnosis of acute
  respiratory failure due to AECB. Hypercapnic
  respiratory failure was documented by the
  physician in the progress notes. He was
  significantly dyspneic and with a frequent cough
  that substantially interferes with his ability to
  even communicate ... with an assessment of
  "respiratory failure due to acute exacerbation of
  COPD".
• The initial ABGs taken in the ER was after the
  patient was receiving O2 via nasal cannula. The
  patient is on home 02, received 02 from EMS, and
  the Interdisciplinary progress note (in the ER
  and before the ABGs were taken) stated the
  patient's respirations were "rapid and shallow,
  R38 labored, SPO2 - 82-84 on 4 L O2".
• He was admitted to the ICU, given IV antibiotics,
  corticosteroids, aerosol bronchodilators, and
  oxygen.
• Please refer to the attached documentation with
  noted labs, times, etc. ".

53
Risk vs. Opportunity

• Check points
• SOLID
• Accurate
• Supportive coding documentation
• NO gaps
• Consistent description of the patient, the care,
  the services provided, including the
  decision-making
• Evidence-based
• Tie up all loose ends
• Stand the test of time

54
Driving the Distance

• Develop a current state process and map to your
  common goal destination

• Keep going no matter what the barriers may be

55
Working Together

• Team and relationship building
• Development of partnerships within and outside
  the facility
• Dancing to the same tune

56
In Closing
Audience Questions
Thank you for attending Margi Brown, RHIA, CCS,
CCS-P, CPC, CCDS AHIMA ICD-10 Certified Trainer
codebrown_at_bellsouth.net