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Defend code assignments to help improve coding quality and reduce take-backs

JustCoding News: Inpatient, August 12, 2015

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While some HIM professionals may feel a sense of relief knowing Recovery Audits are on hold for the remainder of 2015, they should still keep track of denials and appeals and defending code assignments.

Other auditors are still on track and may be looking for the same errors that Recovery Auditors once pinpointed, says Cathie Wilde, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer and director of coding services for MRA Health Information Services in Quincy, Massachusetts.

Most major health plans are tracking claims and flagging denials, making it all the more important for organizations to ensure their coding and documentation is up to par, agrees Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer and ambassador as well as the director of clinical documentation at HRS. "Everybody is jumping on board now with the denials," she says.

In essence, with Recovery Auditor audits on hold, hospitals may have experienced a decrease in the number of audits that must be addressed. This lull in audit activity means now is a good time to examine query processes and physician documentation to ensure your organization is prepared for any audits that come your way. "Ideally, it's good to look at that process when you have a bit more time and are not in the thick of things," Wilde says.

With ICD-10 coming down the pipeline, auditors may not have a handle on how certain diagnoses and procedures should be coded, which is why hospitals will need to carefully review any future ICD-10 audits rather than assuming auditors are correct. "It's all new to everybody, so [auditors] are getting a feel for it as well," Wilde says.

Defend codes, improve quality

The process of defending code assignments or improving coding quality can often help organizations prevent take-backs from Recovery Auditors and other auditors. The HIM director or manager should support coders in the effort to correctly assign codes to help ensure accurate reimbursement and avoid take-backs, Wilde says.

This begins with an organization's ability to justify the codes assigned to its patients' records, she says. If the code assignment cannot be justified by official coding guidelines or Coding Clinic advice or backed up by solid physician documentation, coders should select a more appropriate code. "If you can't justify it, it's likely not the most valid code that you should be using," she says. Some hospitals are not as aggressive about reviewing denials and pursuing appeals; however, it can be advantageous to review the record associated with each denial and draft an appeal letter.

"It's definitely worth the effort," Wilde says. "If you put the time in to code that record and you know you can justify what you've coded, then you certainly should be able to justify the appeal and get reimbursement for that."

Confusion over principal diagnosis

Wilde notes that organizations can take several steps to make it easier to defend code assignments and avoid denials. Tracking trends coupled with adherence to coding guidelines can help avoid some challenges when claims are submitted.

For starters, when reporting additional diagnoses, ensure that diagnosis codes submitted on a claim are supported by the criteria outlined in Section III of the ICD-9-CM Official Guidelines for Coding and Reporting. Other diagnoses are interpreted as additional conditions that affect patient care in terms of requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, or increased nursing care and/or monitoring, Wilde says.

Failure to ensure that the diagnoses meet criteria may affect coverage, she says.

In some instances, more than one diagnosis could potentially meet the definition of a principal diagnosis, Wilde says. When considering sequencing one diagnosis over another, start by ensuring that it meets the definition of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."

For example, a patient may come into the hospital for one condition but lab work completed at the hospital indicates the patient has another condition, such as cancer. In this instance, the cancer was present on admission, but it wasn't what prompted the patient to visit the hospital or be admitted. Situations like this require some critical thinking so the appropriate principal diagnosis can be assigned based on the condition that is the root cause of the patient's admission, Wilde says.

"Make sure you're really paying attention to why the patient came into the hospital and what resources were invested in treating that patient during the course of hospitalization," she says. "If one condition weighs more than another in terms of treatment and workup, then you would defer more to that one."

Documentation and queries

Conflicting documentation from multiple providers is not only a headache for coding and HIM, but can often lead to denials.

For example, a resident may document metabolic encephalopathy in the progress notes while a patient is admitted to the hospital. Later, the attending physician completes the patient's discharge summary and notes acute confusional state. The documentation of the patient's mental status is conflicting.

However, Coding Clinic states coders must defer to the attending physician for the final word on the patient's diagnosis. Did the attending physician intend to indicate the patient was treated for acute confusional state, or was the actual condition metabolic encephalopathy?

"That's a documentation issue that the coder should pick up on and query with the physician," Wilde says. "If you really mean metabolic encephalopathy, don't just document acute confusional state."

HIM can use principal diagnosis queries for situations like this as teachable moments for clinical documentation improvement (CDI) specialists and for physician education, she says. In addition to querying scenarios with conflicting documentation, coders should also query physicians if the documentation is muddled and the principal diagnosis is unclear. Querying in either instance can help defend code assignments in the event of a denial. "If it does get a denial, that query supports your code further and in fact may negate the denial because you have that additional piece of documentation," Wilde says.

However, says Carr, documenting conditions is not enough. A physician can document the name of a patient's medical condition on every page of the medical records, but if it's not supported by clinical indicators it may be at risk for a denial, she says.

This also ties into the issue of conflicting documentation from multiple providers. For example, a physician may document metabolic encephalopathy, but a consultant's review of systems in the history and physical note the patient is alert and oriented. These clinical indicators do not match up with the definition of encephalopathy, which is acute delirium or acute confusional state.

How can you defend your diagnosis of encephalopathy when the physician is documenting that the patient is alert and oriented?" Carr says. "We have to defend that now and we will have to defend it in ICD-10."

A good rule of thumb is to remember the keywords coders may look for in the record to assign a code are often the same ones that auditors are looking for, she says. If these terms are not in the record, the codes may not be supported, and the claim will likely be denied. Clinical indicators are not only critical to selecting the right code the first time, but are also necessary when coders reach a point where they must query to assign the correct code, Carr says.

"In order to be compliant with our coding guidelines, the clinical indicators must be present," she says. "You've got to have clinical indicators to have a compliant query. If you don't have clinical indicators, it could be considered a leading query and result in compliance issues for the organization."

CDI specialists are well suited to ensure clinical indicators and necessary documentation are included in the record, Carr says. If someone in your organization doesn't question inadequate documentation to support coding, auditors likely will. Pre-bill auditing can often help avoid denials and thus minimize the appeal process. Carr notes she frequently sees organizations receive denials for accelerated hypertension, acute renal failure, acute respiratory failure, sepsis, and encephalopathy.

Consider devising a reference sheet that lets coders and others within the organization know what to look for to support the assignment of certain codes for these conditions, she says. If other conditions are the cause of denials at your organization, develop reference sheets specific to those problem areas.

The denial and appeal process

Consider the following processes when working through denials and appeals:

  • Track each denial and appeal. Organize documentation so it is easy to find each denial and appeal. Lay out a process that allows workforce members to quickly and easily access this information and follow up on pending denials and appeals. This is also useful when appealing claims a second time for reconsideration, Wilde says.
  • Each hospital will operate differently in terms of its process and whom the denials and appeals will be directed to, but HIM is typically tasked with this responsibility.

    The denials and subsequent appeals are likely funneled to the coding manager, who may then direct it to the coder to obtain rationale for the coding that was originally submitted. The conversation between the coding manager and the coder is often the first step in determining whether a denial may be able to be appealed, Wilde says.

  • Pay attention to medical record documentation. Ensure that you submit the complete medical record when appealing a denial. Seek physician involvement, if necessary, to support your appeal. The physician cannot add any clinical documentation that is not already present in the medical record, but he or she can clarify and summarize the facts already documented in order to support the coding, Wilde says.
  • "Outline the details in your appeal letter to substantiate your codes," she says. "If you can support your appeal by listing pertinent clinical findings, official guidelines, and references and notations in the medical record, such as where you found information on the progress note, I think that helps."

    The appeal letter should not be long winded, but should contain enough data to support coding and should specifically address the issues identified by auditors. The appeal letter should be succinct and to the point, outlining supportive documentation, Wilde says.

    Unfortunately, not all appealed denials will be successful. However, if the organization feels strongly about the validity of its coding, there is often an opportunity for second-level reconsideration. "If you get denied, it's well worth the effort to pursue further the appeal to next level if you really believe that you have coded it correctly based on the documentation and official coding guidelines," Wilde says.

  • Keep coders in the loop. HIM should work with coding managers—if they are not already the ones overseeing coders—to ensure coders are aware of each of each denial and appeal.
  • "Most hospitals do have a coding manager or coding supervisor, and those are the people who really do the appeals," Wilde says. While HIM should be involved in this process, the coding manager and coders have the coding expertise and can use that knowledge to help outline letters for successful appeal.

    Coders should be aware of the areas auditors are focusing on so they can work on improving documentation and queries when necessary. Coupled with official coding guidance, denials and appeals can serve as a great learning tool for coders, Wilde says. "You want to make sure the denial doesn't happen again, because you don't want to have to go through this whole process again if it's unnecessary," she says.

In some instances, when presented with a denial for justification of coding, the coder (and coding manger) may agree with the auditor's rationale. This is also a learning experience for the coder and underscores the need for hospitals to engage coders in the denial and appeal process, Wilde says.

Editor’s note: This article originally appeared in the August issue of Medical Records Briefing. Email your questions to associate product manager Michelle A. Leppert, CPC, at mleppert@hcpro.com.



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