It is also important for organizations to circumvent possible overreactions to denials. An overreaction mentioned in
the toolkit is “no longer allowing a particular diagnosis to be
coded just because it is frequently denied.” A more effective
approach would be to understand why the diagnosis has become a target—then processes can be created or streamlined
to decrease prospective risks for such denials.
Organizations can also use denial data to work with provider service lines to establish clinical evidence guidelines
that are usually associated with high-risk diagnoses. CDI
and coding professionals can then use these clinical guidelines to identify when clinical validation is required from
providers. Clinical validation is the process of validating the
clinical evidence within the health record to support each
diagnosis and procedure that is documented. Providers can
also utilize peer-to-peer alliances between physician liaisons and the medical groups to incorporate the guidelines
into provider practices.
CDI and coding programs can assist organizations in preventing denials due to missing or inaccurate documentation.
When the health record provides accurate and thorough documentation, the probability of having a condition, treatment,
or code denied for reimbursement is lessened. Many inpatient CDI teams perform concurrent reviews of the health record documentation at the time care is being provided. CDI
teams that perform concurrent reviews are invaluable in ensuring accurate health record documentation is in place at
the time of discharge.
A query (which may be referred to as a “clarification” in some
organizations) is sent by the CDI and/or coding professional
when a question arises regarding the health record documentation. The provider reviews the query to determine if further
specificity can be brought into the documentation. It is essential that the documentation is specific enough to ensure that
the principal diagnosis or procedure, as well as all secondary diagnoses and procedures, is accurately recognized and
coded correctly. The documentation should also support the
present on admission (POA) status. If it is unclear whether a
condition was POA or developed after admission, then a query
may be needed.
DRG validation is another process organizations can implement. This is a process that reviews for the correct assignment of all diagnoses and procedures that impact DRG assignment, ensuring that they are coded correctly based on
the ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting.
In order to capture a diagnosis, the condition must meet any
combination of these:
Increase nursing care
Extended length of hospital stay
The CDI and Coding Collaboration in Denials Management
Toolkit also provides several appendices with examples of denial codes, appeal letters, query examples, policies and procedures, job descriptions, and interview questions, as well
as a pre- and post-hire assessment and documents that are
frequently not part of the legal medical record. To access the
toolkit, visit www.ahimastore.org. It will also be available in
AHIMA’s HIM Body of Knowledge at http://bok.ahima.org. ¢
Darla Blevins, BSN, RN, IQCI
Tammy Combs, RN, MSN, CCS, CCDS, CDIP
Cheryl Ericson, MS, RN, CCDS, CDIP
Crystal M. Isom, RHIA, CCS
Patricia Jones, RHIA
Katherine Kozlowski, RHIA, CCS, CDIP
Irene Lovano, RN, CCDS
Faith McNicholas, RHIT, CPC, CPCD, PCS, CDC
Therese Peyton, BSN, RN, CCDS
3/7/18 3:08 PM