Note from the Instructor: When it comes to denials prevention, consistency is key

By Allen Frady, RN-BSN, CCDS, CCS, CRC

Generally speaking, developing consistent query policies and procedures for both coding and CDI staff helps keep everyone in compliance with coding regulations. Similarly, work with clinicians, CDI specialists, and coders as often as possible to develop uniform clinical parameters for common diagnoses to help everyone involved understand when a query might be clinically appropriate. Inconsistency among staff may be the very reason for the denial.

Speaking of consistency, the attending physician seemingly disagreed with another provider, insurers may cite the documentation as “inconsistent” and summarily remove the diagnosis, denying that portion of the claim. This may happen even if the attending physician didn’t actually disagree from a clinical language standpoint, as the denial stems from a clinical argument based on the coding language and not on evidence contained within the medical record. A proper clinical interpretation should supersede an arbitrary and obviously incorrect coding nomenclature “gotchya” moment. It should, but it doesn’t. It would seem part of the standards as set out by the Cooperating Parties (as spelled out in the Official Guidelines for Coding and Reporting) is uniformly ignored. So, watch for auditors and which use nomenclature tricks inherent to the complexities in ICD-10 indexing to impose a denial.

The standard, by the way, says that coders should accurately capture the conditions based on the provider documentation and the information contained within the medical record. These denials usually met a dogmatic literal indexing of the physician’s wording in ICD-10, but completely fail at accurately capturing the second part of that definition which is supposed to be the true “information contained within the record.” Here it looks like the denial experts choose half the definition to use in their favor, while conveniently forgetting about the other half of that edict.

Best practice therefor means the attending physician should restate all clinical diagnoses which were monitored, evaluated, or treated within the stay, including those made by other physicians and not just limited to those conditions addressed by the attending him/herself. AHA Coding Clinic for ICD-10-CM Third Quarter, 2016 (p. 26) offers up some guidance which can be used for educational purposes here:

“It is the responsibility of the attending physician to gather and collate all of the findings from the consultants and other providers involved in the care of the patient. The plan of care is based on the attending physician’s evaluation, interpretation, and collation of all the findings (i.e., pathology, radiology, and laboratory results).”

Rest assured that auditors will use this against your facility when an attending claims he or she simply does not have to comment on a diagnosis because he or she didn’t personally assess or manage it on a particular day. This piece of Coding Clinic has gone somewhat unnoticed as it has been overshadowed by controversy with regards to what has infamously become known as simply “Guideline 19,” which stipulates that a coder should code whatever diagnosis the physician provides without censoring a diagnosis based on indicators.

Editor’s note: Frady is a CDI education specialist for BLR Healthcare in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement- boot-camp-1.