Clinical Support Versus Documentation: Determining the Best Approach for Appealing Denials

Transcription

1 Clinical Support Versus Documentation: Determining the Best Approach for Appealing Denials Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM Recovery Analytics November 21, 2013 SLIDE 1

2 Disclaimer Panacea has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless, the ultimate responsibility for correct use of the coding system and the publication lies with the user. Panacea, its employees, agents and staff make no representation, warranty or guarantee that this information is error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company will bear no responsibility or liability for the results or consequences of the use of this material. The publication is provided as is without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The information presented is based on the experience and interpretation of the publisher. Though all of the information has been carefully researched and checked for accuracy and completeness, the publisher does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. Current Procedural Terminology (CPT ) is copyright 2011 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of the American Medical Association. Copyright 2013 by Panacea. All rights reserved. No part of this presentation may be reproduced in any form whatsoever without written permission from the publisher Published by Panacea, 287 East Sixth Street, Suite 400, St. Paul, MN SLIDE 2

3 Disclaimer This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner. The author is not providing or offering legal advice, but rather practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation. SLIDE 3

4 Learning Objectives From this timely webcast one that features case studies you will... Understand clinical validation denials Discover high target areas Review sample clinical validation denials Be able to develop smart strategies for crafting bulletproof appeals Learn how to implement an escalation policy for discrepancies among clinical teams Receive important "next steps" to protect yourself from denials SLIDE 4

5 What s The Challenge Translation of medical language/practice to coding guidelines Changing trend toward quality, statistical analysis, coding transition Physician frustration Understanding of the Clinical and Coding Relationship SLIDE 5

6 Haven t We Seen This Before DRG 89 Simple Pneumonia and Pleurisy It appears that a substantial portion of the errors in assignment for "pneumonia and pleurisy resulted when physicians identified a similar but incorrect respiratory or infectious disease the principal diagnosis on the attestation sheet. OIG Report ~ OAI June 1989 SLIDE 6

7 Haven t We Seen This Before DRG 89 Simple Pneumonia and Pleurisy The DRG 96 (bronchitis and asthma) should have substituted for DRG 89 in 40.3 percent of errors. OIG Report ~ OAI June 1989 SLIDE 7

8 Haven t We Seen This DRG 89 Simple Pneumonia and Pleurisy Recommendations The Health Care Financing Administration (HCFA) should direct the peer review organizations to educate hospitals and physicians about distinguishing between (1) pneumonia and (2) bronchitis-asthma as principal diagnoses. The HCFA should review the non-specific ICD-CM codes 485 and 486 in DRG 89 bills for quality of care. OIG Report ~ OAI June 1989 SLIDE 8

9 Root of Denial Selection of the Principal Diagnosis When a CC/MCC is present as secondary, it may affect DRG assignment. Cases w/ a single CC/MCC are a governmental/commercial payer coding/drg target. Denials are due to the secondary diagnosis being billed and not substantiated clinically in the medical record. SLIDE 9

10 Opposing Factors Documentation Clinical Information SLIDE 10

11 How do we meet the Challenge? Communication Coding CDI Team Quality IT Physicians Embrace the need for Quality Documentation to yield Quality Coding for Quality Data! SLIDE 11

12 Clinical and Coding Still a Problem CMS Revised RAC Statement of Work (SOW) Clinical Validation Reviews Clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials. SLIDE 12

13 Clinical and Coding Still a Problem Some hospitals may choose to code the record prior to receiving the complete medical record (e.g., not waiting for discharge summary or operative reports). Hospitals do this at their own risk since they are responsible for reporting codes that accurately reflect the patient's conditions and procedures. Therefore hospitals may increase their chance of errors by choosing to code the case prior to receiving the complete medical record. Recovery Auditors will not take this into consideration. MLN Matters# - SE1121 SLIDE 13

14 Clinical and Coding Still a Problem As with all codes, clinical evidence should be present in the medical record to support code assignment. The Uniform Hospital Discharge Data Set (UHDDS) Guidelines for coding and reporting secondary diagnosis allow the reporting of any condition that is clinically evaluated, diagnostically tested for, therapeutically treated, or increases nursing care or the length of stay of the patient. MLN Matters# - SE1121 SLIDE 14

15 Example Coding Denial - I Denial Rationale/Reason MSDRG 180 Respiratory Neoplasm with MCC 486 Pneumonia, Unspecified The reviewer has recommended the sequencing of pneumonia, 486, for this episode of care. In our review of the medical record, the physician s diagnosis of 486, Pneumonia, Unspecified as the Principal Diagnosis is most reflective of a diagnosis that me. Meets Coding Clinic guidance and Official Coding Guidelines for being addressed, treated, not ruled out, and restated at the time of discharge; moreover clinically evident, and appropriate as principal. SLIDE 15

16 Example Coding Denial - I Documentation Facts/Support: Attending physician states on history and physical likely pneumonitis and or bronchitis with failed outpatient treatment. Temperature noted 100.3, to 99.4, 98.5 following initiation of antibiotics. Respiratory rate 18-26, Blood pressure 118/75, pulse 133 The patient was started on IV antibiotics in broad coverage, Levaquin, Zosyn, and Vancomycin with O2 and IV steroids. This coverage is widely used for pneumonia - Levaquin (bacterial infections including pneumonia), Zyvox (utilized for gram negative infections including nosocomial and community acquired pneumonia), Vancomycin (bacterial infections including pneumonia). Patient had a history of lung cancer with metastasis to the brain in remission, status post treatment. Discharge summary restates findings on chest angiogram that pneumonitis could not be excluded. Pneumonia Severity Index Class V Risk Class V, >>2.8% mortality. Hospitalization recommended based on risk. SLIDE 16

17 Example Coding Denial - I Throughout progress notes, multiple daily progress state the diagnosis of obstructive pneumonia in which there is CODING CLINIC GUIDANCE If pneumonia is documented as obstructive and the obstructive process is identified (i.e. tumor), assign a code for the pneumonia and a code for the obstructive process. Sequencing depends upon the circumstances of the admission. Coding Clinic for ICD-9- CM, Q pg. 8. The Official Guidelines for Coding and Reporting, Section II, B., state, When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise. See also Coding Clinic, Second Quarter 1990, page 4, for additional examples. The patient has a well-documented and supported diagnosis of pneumonia. Based on the Coding Clinic guidance referenced above and Official Coding Guidelines for Coding and Reporting, pneumonia is the most appropriate code to be assigned as the principal SLIDE 17

18 Example Coding Denial - II Denial Rationale/Reason MSDRG 417 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. W MCC Calculus of the Gallbladder with Acute Cholecystitis, Without Mention of Obstruction The reviewer has recommended the resequencing of Calculus of the Gallbladder with Acute Cholecystitis, Without Mention of Obstruction from the principal diagnosis position to a secondary diagnosis., recommending Acute Pancreatitis as the principal. In our review of the medical record, the diagnosis of is coded appropriately as principal and resequencing would be inconsistent with coding guidance. Please review the information to see detailed explanation of how Coding Clinic/Official Coding Guidelines informs coders of how this code should be assigned based on documentation in the medical record. SLIDE 18

19 Example Coding Denial - II Documentation Facts/Support: Physician states documentation throughout the medical record reflects the diagnosis of acute cholecystitis and gallstones as well as acute; gallstone pancreatitis. This is documented on history and physician, progress notes, consultation reports as well as the Final Discharge Summary. The two most common and important risk factors for acute pancreatitis are gallstones and alcohol consumption. (Patient has no history of alcohol). Due to the diagnosis of gallstone pancreatitis, surgery to remove the gallbladder was recommended to prevent recurrence of the pancreatitis. Patient underwent a cholecystectomy with pathology report showing gangrenous cholecystitis with gallstones with PATENT (open) cystic duct. Discharge Summary states cause of pancreatitis due to gallstones. SLIDE 19

20 Example Coding Denial - II Clarification - gallstone pancreatitis Coding Clinic, Second Quarter 1996 Page: 13 to 15 Effective with discharges: May 1, 1996 Question: In previous coding advice, Coding Clinic indicated that gallstone pancreatitis is coded to 577.1, Chronic pancreatitis, as the principal diagnosis, and , Calculus of bile duct without mention of cholecystitis, with obstruction, as an additional diagnosis. However, the patient's record indicates gallstone pancreatitis and acute pancreatitis. Upon querying our physician, she states that gallstone pancreatitis is usually associated with acute pancreatitis. What is the correct code assignment in this case? Answer: If the patient presents with acute pancreatitis, assign code 577.0, Acute pancreatitis. Assign the appropriate code from category 574, Cholelithiasis, as an additional diagnosis depending upon the documentation in the medical record. Sequencing depends upon the circumstances of the admission. SLIDE 20

21 Example Coding Denial - II Question: If a patient has gallstone pancreatitis and documented acute cholecystitis and/or cholelithiasis, would this be the principal diagnosis over the pancreatitis? Answer: Sequencing depends upon the circumstances of the admission. Question: A patient undergoes cholecystectomy for gallstone pancreatitis. The pathology report identifies chronic cholecystitis and cholelithiasis. No common bile duct stones are found. Is , Calculus of the bile duct without mention of cholecystitis, with obstruction, always used for gallstone pancreatitis? Answer: Do not assume a bile duct obstruction for gallstone pancreatitis. Since no common bile duct stones were found, assign code 574.1x, Calculus of gallstone with other cholecystitis. SLIDE 21

22 Example Coding Denial - II ICD-9 CM Official Coding Guidelines for Coding and Reporting; Effective Two or more diagnoses that equally meet the definition for principal diagnosis In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. The patient has a well-documented and supported diagnosis of Calculus of the Gallbladder with Acute Cholecystitis, Without Mention of Obstruction; primary problem with resolution obtained via surgery. Overlooking evidence of these facts would be inconsistent with Official Coding Guidelines for Coding and Reporting as well as AHA Coding Clinic. SLIDE 22

23 Example Coding Denial - III Denial Rationale/Reason Septicemia MSDRG 871 Septicemia w/o MV 96+ hours with MCC The reviewer has recommended the removal of the sepsis diagnoses for this episode of care. In our review of the medical record, the physician s diagnosis is reflective of a diagnosis that meets coding guidelines for being addressed, treated, not ruled out, and restated at the time of discharge; moreover clinically evident, and appropriate as principal. SLIDE 23

24 Example Coding Denial - III Documentation Facts/Support: Please review the clinical findings from the record as described below for support of the sepsis diagnosis as coded (see clinical evidence of septicemia as published by AHA Coding Clinic 2 nd qtr 2000 and highlighted below (AHA Coding Clinic does not provide clinic advice): Sepsis: Decreased/Altered mental status/deficits Patient hypotensive with blood pressures 60/unable to measure and 69/36 at the time of admission (as well as 90s/60s) and as noted on History and Physical 56/40. Pulse at 90 per minute Respirations was at 37 and respiratory rate noted to be 18 per minute as noted on History and Physical with a pulse of 75. Initially treatment was carried out with Vancomycin at 1000 mg IV. Temperature was initially at low; 97.6 with spike up to Patient with Creatinine 4.9 Patients had uncontrolled blood sugars throughout admission. Patients with diabetes mellitus have an increased risk of developing infections and sepsis as stated by, Sachin Yende from the National Institute of General Medical Sciences, National Institute of Health;(Crit Care. 2009; 13(1): 117). White blood cell count significantly elevated at Decreased capillary refill Documentation throughout admission for sepsis/septic shock with statement from MD that there was a septic situation - pg. 17 SLIDE 24

25 Example Coding Denial - IV DRG 823; Lymphoma and nonacute leukemia with other OR procedure with MCC ; Systolic heart failure, acute on chronic, Denial Reason/Rationale Remove code SLIDE 25

26 Example Coding Denial - IV Documentation Facts/Support: This 90 year old male with a known history of CHF (Congestive Heart Failure) with CAD and cardiomyopathy who presented to the ED with shortness of breath also noted while sitting or at rest. There was also documentation of pitting edema with distended neck veins. As noted at the time of admission in the ED the patient had a documented diagnosis of acute congestive heart failure (pg 20 of ED record) which was addressed and treated with 20 mg of Lasix IV push and subsequent 80 mg via IV push. Patient was placed on daily weights with fluid loss. Patient elevated for resting. Physician restated diagnosis on progress note dated 3/30/12, at the time of discharge. As stated in Coding Clinic First Quarter 2009 pg.8; acute exacerbation of a chronic condition (CHF) is coded as acute on chronic with an additional code of the systolic or diastolic dysfunction. SLIDE 26

27 Decision to Appeal Review denial rationale/reason Analyze chart documentation/clinical support Is documentation consistent? Was condition addressed/treated? Does clinical information support code assignment? Did physician restate/validate clinical information? Was there a query at the time of coding? Was code assigned reflective of severity of condition? Official Coding Guidance including Coding Clinic Understanding of disease process required SLIDE 27

28 Who Should Appeal All providers as appropriate Coding Clinical Documentation Improvement Specialists Physicians SLIDE 28

29 Why Should We Appeal Documentation in the chart Improve internal processes Why Appeal? Clinical Indicators present Opportunity to educate internally Opportunity to educate auditor SLIDE 29

30 Support for Clinical Coding Denials Official Coding Guidelines for Coding and Reporting AHA Coding Clinic Documentation in the chart Alphabetic/Tabular Index Physician Letter/Statement Medical support; i.e.,pathophysiology Medication reference Clinical standards of care SLIDE 30

31 Support for Clinical Coding Denials Uniform Hospital Discharge Data Set (UHDDS) Principal diagnosis (inpatient): The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. SLIDE 31

32 Support for Clinical Coding Denials The definition for other diagnoses includes additional conditions that affect patient care in terms of requiring: Clinical evaluation; or Therapeutic treatment; or Diagnostic procedures: or Extended length of hospital stay; or Increased nursing care and/or monitoring SLIDE 32

33 Support for Clinical Coding Denials Inpatients diagnosed with a possible, probable, etc. at the time of discharge is considered to be an established diagnosis and should be coded and reported as though the diagnosis were established. Other terms that fit the definition of a probable or suspected condition are: "consistent with," "compatible with," "indicative of," "suggestive of," "appears to be," and "comparable with." SLIDE 33

34 Support for Clinical Coding Denials Clinical Information Laboratory Radiology Respiratory Nursing Notes Cardiac tests Speech Therapy Dietary DON T FORGET UR REVIEW!! SLIDE 34

35 Coding References/Resources Must Have: Current ICD-9-CM book Current CPT book Official Coding Guidelines AHA Coding Clinic on ICD-9-CM AMA CPT Assistant Other Coding References: Medical dictionary Anatomy & physiology book Coder's Desk Reference for Procedures (Ingenix) Medical abbreviations book Merck Manual (diseases) SLIDE 35

36 References Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/SE1121.pdf Guidance/Guidance/Manuals/Downloads/pim83 c06.pdf SLIDE 36

37 THANK YOU FOR ATTENDING SLIDE 37