CDI Week 2019 Q&A: CDI and denials management

As part of the ninth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Johanne “Jo” Brautigam, RN, BSN, CCDS, CDI manager at Roper St. Francis in Charleston, South Carolina, the president-elect for the South Carolina ACDIS local chapter, and a member of the 2019 CDI Week Committee, answered these questions. Contact her at Johanne.brautigam@rsfh.com.

Q: According to the 2019 CDI Week Industry Survey, 56.51% of respondents are currently involved in the denials management or appeals process. Is your CDI team involved in this process?
A: I involve the whole CDI team with denials. We try to be proactive and query those “hot topics” like sepsis and malnutrition (to name a couple). Looking at denials helps illustrate what CDI specialists need to secure in the documentation.

As far as appeals, the CDI medical director does a lot of work with our coding appeals specialist. The second-level CDI reviewer and I usually take a look to make sure sending it to the medical director is worth her time. If there is a specific chart that has an issue, sometimes we will include the CDI specialist who originally reviewed the case as a learning opportunity.

Q: Does your CDI team help with all types of denials or just a particular subset? How did you decide where to help out?  
A: We work on the coding/documentation denials and case management works on the medical necessity denials, as we are separate departments. Our CDI team’s focus is on the clinical validation needs with denials. But we also work on concepts such as the following:

• No apparent distress with acute respiratory failure
• Well nourished with severe protein calorie malnutrition

Contradictions are easy to catch, and as minor as they seem, they can really drop a DRG.

Q: How long have you been involved with the denials management/appeals process? How have you seen the denials landscape change over that time period?
A: We have been involved in the appeals process for a couple years. The denials landscape has changed in so many ways. We are seeing more than one code denied, so getting more than one CC or MCC doesn’t protect the DRG anymore.

Next, more than anything, clinical validation has really made appeals difficult. Take sepsis, for example. Validating sepsis on Sepsis-3 criteria is very controversial because the criteria set has not been adopted by CMS (yet), and it was developed to predict sepsis mortality.

On top of denying on validity, the criteria payers use can be different than what your organization uses. KDIGO and RIFLE are the two that come to mind. It’s difficult when we are held to the Official Guidelines for Coding and Reporting, but the payers are not.

Q: What types of diagnoses do you see most frequently denied? How have you worked to fight against those denials?
A: These days, there are a lot of denials for sepsis, acute respiratory failure, acute tubular necrosis, myocardial infarction, and acute congestive heart failure (CHF). Even hyponatremia has come back around. We educate ourselves on these topics and make sure everyone is comfortable with the definitions. We then educate the providers and develop query templates. With acute respiratory failure, we worked with our pulmonologists and intensivists to develop an organizational definition with threshold criteria. We are also involved with our sepsis task force for their accepted sepsis criteria.

Q: What other departments or groups does CDI collaborate with on the denials management/appeals process? In what capacity do they collaborate (e.g., through monthly meetings, during the appeal writing process, etc.)?
A: We collaborated with our dietitians when they adopted the ASPEN criteria to educate the providers. When a severe protein-calorie malnutrition denial comes through, they help with the appeal, especially providing data and references.

Another department we worked with was compliance when we started getting lumbar fusion denials because of the lack of conservative measure documentation. The surgeons actually asked for our help!

Q: According to the Industry Survey, 23.71% of respondents have been involved in the denials management process for less than a year. What would you recommend to them as they ramp up their involvement? Is there anything you wish you’d known when you started out?  
A: Start slow and take one at a time. Look at your denial data and start with the top diagnosis. For us, that was sepsis. My medical director and I worked on a criteria checklist, which the CDI specialists used when writing validation queries. Then we developed a couple validation templates. As they wrote the queries, I had my specialists send them to me first for review before placing them in the chart. As I saw the individual specialists were getting the hang of it, I would release them to write the sepsis clinical validation queries on their own.

What I didn’t realize was how many sepsis validation queries I was going to review, and the need for a quick turnaround time to keep productivity up.

Realize you will have to revise your templates and checklists once you get feedback from providers and your team.  

Q: How do you measure the success of CDI’s involvement with this process? What metrics do you track, and how are you tracking them?
A: From the total number of queries, I report on the percentage of those that are written for clinical validation. I let the chief financial officer know these are diagnoses that we are not having to pay back.

Q: What effect has CDI had on the denials landscape at your organization?  
A: As we work with the providers to make sure the documentation is complete, and clinically accurate, we are seeing success such as with severe protein-calorie malnutrition. The denials for that diagnosis have been reduced. The providers are now asking CDI for more documentation help because they are getting told about denials and want to make sure their documentation is not the cause. 

Q: What would be your best piece of advice for writing an effective appeal letter?
A: First, make sure it is something you can appeal. Read the denial letter carefully; there are explanations as to why you are being denied. These will be your clues for how to build your appeal. Make sure you have all your experts involved from CDI and coding. When you have a great appeal letter, save it—you can use it as a template for other letters.

Q: What can CDI professionals do on the front end to prevent denials on the back end? What can they do even if they don’t work directly with the denials management/appeals process?
A: CDI teams can be proactive by learning the denial “hot topics” for your organization. The ACDIS website is an excellent resource for trends and what other organizations are doing to combat denials. Validating the diagnoses while the patient is in the hospital is easier than after the denial comes back. It also saves all the rework that goes into an appeal. When educating providers, find denial and clinical validation articles to show this is not something you made up.  

Q: Can denials data be leveraged for physician education/engagement? If so, how?
A: Many times, providers have no clue their case has been denied. Showing them the letters is very sobering, and it is amazing how hard they will fight for their patients or expensive procedures. As with queries, sometimes providers will have more information than was documented, so enlisting their help can be beneficial.

Q: For CDI teams looking to get involved in this process, what would you recommend to them as the best first step (e.g., reaching out to a particular person)?  
A: The best first step is to collect information. See what your biggest area for denials is, and I can’t emphasize enough: Start small. One diagnosis at a time. Get comfortable with gaining validation for the diagnoses. Look at it from this point of view: You are not questioning the provider, you are just trying to get more information to support the documentation. When querying for clinical validation, call the provider to help explain what and why you are asking.

Reach out to finance, case management, or the coding denials person/team. Read denial letters and get familiar with the criteria they cite. As we work on one subject to solidify the clinical documentation, the payers seem to find another area to deny. This keeps us in a job!