CDI Week 2020 Q&A: CDI and denials management

As part of the tenth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Nancy Franciotti, BS, RN, CCDS, the CDI manager at Inspira Health, member of the Philadelphia/Southern New Jersey ACDIS local chapter, and a member of the 2020 CDI Week Committee, answered these questions. Contact her at franciottin@ihn.org. For more information about CDI and denials management, read the 2020 CDI Week Industry Survey report. 

Q: According to the 2020 CDI Week Industry Survey, 59.19% of respondents are currently involved in the denials management process. Is your CDI team involved in this process? When did you first get involved?

A: The CDI team at Inspira got involved in clinical validation denials in 2018. Before that, coding was handling the clinical validation denials, but needed clinical review to combat denials that are issued by an nurse through the private insurance company or through a Recovery Auditor.

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: CDI is currently only working on the clinical validation denials—those denials in which the payer recommends a downgrade of DRG because they feel the clinical indicators do not support the condition being denied, and or they dispute the diagnostic criteria utilized in making the diagnosis. For example, Sepsis-2 versus Sepsis-3 criteria.

Q: What types of diagnoses do you see most frequently denied?

A: Our top denials are for sepsis, respiratory failure, and encephalopathy. The majority of my appeal letters are in response to denials for these conditions.

Q: What other departments or groups does CDI collaborate with on the denials management process? In what capacity do they collaborate?

A: We collaborate with coding primarily in the drafting of an appeal letter.

Q: According to the Industry Survey, nearly 41% of respondents’ CDI departments are not involved in the denials management process. Why do you think it’s important for CDI to be involved?

A: CDI team is uniquely qualified in assisting with clinical validation denials and DRG downgrades due to their combined clinical and coding knowledge. The CDI team is able to interpret clinical indicators and apply coding concepts in evaluating whether or not a denial is appropriate and to identify corroborating clinical criteria supporting the condition under denial.

Q: What would be your best piece of advice for writing an effective appeal letter?

A: Step one: Get angry! The payer is trying to deny payment for a condition that was evaluated, monitored, may have extended the patient’s length of stay, and required treatment or other resources.

Step two: I keep the denial letter in one screen addressing the specific nature of the denial.

Step three: Know your clinical criteria. Is the payer denying the sepsis diagnosis based on Sequential Organ Failure Assessment (SOFA) criteria? Are your physicians using Sepsis-2 or Sepsis-3 per the Surviving Sepsis Campaign?

Step four: Review your patient’s record for clinical indicators and treatment of the condition.

Step five: Draft your letter. In one successful appeal, I began by asserting for the coding of diagnosis under dispute, in this case, metabolic encephalopathy. I described the patient’s presentation and objective clinical criteria: febrile, pulse 106, white blood cell count 12.2, and evidence of e-coli urinary tract infection.

Then, I added The National Institute of Neurologic Disorders and Stroke (NINDS) description of encephalopathy, “any diffuse disease of the brain that alters brain function.” Then I disputed the payer’s suggested replacement diagnosis of dementia with behavioral disturbance, by again applying the nationally recognized criteria for that diagnosis. As you can imagine, this is a labor and time intensive task.

I do recommend the ACDIS Pocket Guide as an essential tool in writing these appeal letters. I also keep a file of all my appeal 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: By nature of the mission of CDI—improvement in the quality and integrity of the documentation—one would hope that would decrease denials. Have a care for those conditions which seem to be denial targets. Encephalopathy is a condition which requires major resource consumption, in the form of increased nursing care as the alteration in mental status is so dangerous to the patient and prevents discharge until patient has regained mental status. With regards to sepsis, use criteria from both Sepsis-2 and Sepsis-3, cite as many clinical indicators as are present. For respiratory failure, utilize the P/F ratio calculation and describe the patient’s distress as completely as possible.