From the Forum: Denial proofing queries

Whether it be medical necessity, clinical validation, or coding-related—denials seem always on the rise. And those involved in denials management and appeals know how far reaching the problem has become.

CDI departments that save their queries as part of the permanent medical record may also see their own queries showing up in the denials, according to a recent ACDIS Forum discussion, principally focused on a denial related to the multiple-choice options offered in a query. One facility, according to the Forum thread, received a denial because the query did not provide options for both “other” and “clinically undetermined/unable to determine” responses. Since the CDI specialist thought one option or the other would be compliant, they removed the “unable to determine” option from the template.

“I would say that it’s better (and best) practice to include the options of ‘unable to determine’ and ‘other’ to safeguard your queries from such insurance practices and increased scrutiny from external audits and reviewers,” wrote Angelica Naylor, MBA, BSN, RN, CCDS, supervisor of the clinical documentation management program at North Kansas City Hospital in Missouri.

“I do feel like leaving the ‘unable to determine’ on the query is an easy denial prevention strategy,” wrote Amanda Just, RN, BSN, system manager of CDI at Integris in Mustang, Oklahoma. “It’s already included on all our query templates so I updated and educated my CDI [staff about its importance].”

The term “unable to determine” as an option can be problematic as well when it comes to denials,  added April Floyd, RN, CCDS, director of CDI at Anderson Regional Medical Center in Meridian, Mississippi.

“We actually had a denial from a commercial payer based on the ‘unable to determine’ versus ‘clinically unable to determine’—really, I can’t make this stuff up,” she wrote. “It was overturned. [Later], however, I went into our templates and updated them to ‘clinically unable to determine’ just to avoid future issues.”

Naylor also recommends looking at the diagnoses offered as options in the list—do they all offer a positive financial benefit? If so, an auditor may deny the claim based on that alone.

“I have even established query expectations to include a non-impacting option when asking for an impacting option,” she wrote. “We had a denial for encephalopathy, which stated that we did not provide the physician with an alternative option for ‘altered mental status.’”

At the end of the day, given the rising tide of denials, CDI specialists should be careful to write compliant queries that are above reproach, says Naylor.

“When your clarifications are very solid and credible with multiple options, there is little room for scrutiny or denials,” she wrote. “Strong query practice essentially mitigates denials, which is also an advantage or benefit to having a CDI department.”

Editor’s note: This article’s content was taken from recent posts on the ACDIS Forum. To participate in the Forum, click here. ACDIS recently created a Forum thread specifically for denials. ACDIS members are encouraged to ask their denials-related questions and post sample situations there for constructive conversation and educational purposes. If you have any questions regarding this or the Forum in general, please email ACDIS Editor Linnea Archibald (larchibald@acdis.org).