For the last year, I’ve been fighting insurances.

How?

Helping our appeals team fight denials.

Mostly, clinical validation denials.

What does that mean?

(Clinicians, don’t close this email now. This has implications for you)

First, there’s a difference between coding and clinical validation.

Coding guidelines dictate that coders take diagnoses from provider documentation and convert them to ICD10 codes. Coders are usually not clinical. If it’s documented, they code it (mostly without question).

But clinical validation asks, “Is that documented diagnoses truly present?”

Why is that important?

With the DRG system, each diagnosis has a dollar amount attached to it.

With each diagnosis, you’re claiming certain services were provided. But if that diagnosis didn’t really exist?

Well, under the False Claims Act that’s fraud.

For insurances, that’s money you’re asking them to pay you that you don’t deserve. So, they deny that claim and deny that payment.

Sometimes they’re right.

Sometimes they’re not.

And when they’re not, we fight back…with appeals.

Top Medical Denials

This will vary from hospital to hospital, but our top three were:

1. Respiratory failure (27%)

2. Sepsis & Septic Shock (22%)

3. Encephalopathy (12%)

But denials also included:

• Acute blood loss anemia

• Malnutrition

• Acidosis

• Depression

• Myocardial Infarction

• Heart failure

• COVID 19 Pneumonia

• Pneumonias

• COPD with exacerbation

• AKI

• UTI

The secrets to avoiding those denials are in my newsletter issues, linked above.

So, in reviewing those denials, what lessons can we learn?

Lessons Learned

1. Don’t document respiratory failure when the patient never required supplemental oxygen. This is actually remarkable as…

2. It seems almost every patient in the hospital gets placed on 2L NC. This has been a pet peeve of mine since residency. Given that fact, it’s difficult to argue to insurances that respiratory failure existed unless they are on more than 2L NC. It’s also helpful to have clear documentation of desaturation <91% and description that the patient was in respiratory distress. Documentation of respiratory distress goes a long way in proving that the patient truly had respiratory failure.

3. Use “ruled out” liberally. Ruled out” tells the coder “Don’t code this” (and also important in communicating to other members of the care team). Often presumptive diagnoses are introduced early but copied forward despite tests which argue against that diagnosis. This is a problem with copy/paste and you should delete that diagnosis from your note after ruling it out. UTI was a frequent example. Urine cultures were frequently negative, but “UTI” was persistently documented. Sometimes we do treat for a UTI despite negative cultures, but if that’s the case then you must explicitly explain that. If not, we have no defense for appeal. Another diagnosis that needs a heavy use of “ruled out?”

4. Sepsis. Many insurances are using Sepsis-3 criteria. Recall that SIRS is a screening tool, not a diagnostic one. We should treat empirically for presumed sepsis early, but explicitly state “ruled out” if it’s not ultimately present. The act of note-writing is an important checkpoint to re-assess the validity of your diagnoses.

5. Major diagnoses such as acute heart failure need to be treated with standards of care. If you documented acute heart failure but no diuretics nor inotropes were given, did acute heart failure really exist? Which leads to point #6…

6. Answer your queries, take them seriously, and add more information when necessary. CDI specialists review the chart for clinical validity, among other reasons, and send queries for clarification.

7. For AKI, clearly state a baseline creatinine and the elevated creatinine you’re using to make that diagnosis. If you’re using a reduction of UOP, clearly state that. Too often patients with CKD came in with creatinines which were nowhere close to 1.5 times their baseline, yet AKI was documented. Sometimes it’s presumptive because we’re unsure of their baseline upon admission. Again, remember to use “ruled out” if that’s ultimately not the case.

8. In order to claim that a diagnosis affected your care, it must have MEAT. You must monitor, evaluate, assess OR treat that diagnosis

9. Some conditions are integral to some diagnoses. Confusion is integral to the post-ictal period of a generalized tonic-clonic seizure. So, that patient didn’t also have an acute metabolic encephalopathy. If they did, clearly document a separate reason why they also had acute metabolic encephalopathy.

I’m the first to champion notes as more than “billing receipts,” but although there may have been a time where physicians could ignore the business impacts of their notes, those times are well behind us. Our notes are a vital part of caring for our patients, both clinically and financially. Therefore, just like antibiotics, we must identify ourselves as stewards of our notes - recognizing that they are powerful tools…. but with far-reaching negative impacts if used improperly.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues! Special thanks to my editor Laura Samson, RN, BSN, CCDS.

Cheers,

Robert

When you’re ready, there are two ways I can help you:

Check out The Resident Guide to Clinical Documentation. Join 462+ students who used this course to help them:

• Cut note-writing time by >50%

• Prevent medical errors and lawsuits by using notes to stay organized

• Gain peace of mind knowing how to write shorter yet more effective notes.

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