Q&A: Denials and effective physician communication

January 19, 2017

CDI Strategies - Volume 11, Issue 3

Following ACDIS Radio on January 11, 2016, Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group and a former member of the ACDIS Advisory Board, answered a few more questions relating to denials and effective physician communication.

Q: Have you ever encountered denials based on "late entry" where the CDI query response was received after discharge?

A: Denials based on a “late entry” are a common technique employed by the auditor to deny a reasonable diagnosis. The CDI team can query the physician all the way up to the time of the final coding. Getting the query response and clarification of the documentation and/or diagnosis in the official medical record allows the diagnosis to be coded and included in the final coded record. This should be accomplished no later than 30-days post-discharge.

Q: There are many primary care physicians who round in hospitals and flat out say they don't care about CDI, they’re not interested, and refuse to receive any education. How do we get through to them?

A: Use your physician advisor and/or chief medical officer (CMO) to encourage them and share the value of CDI. Use the physician advisor or CMO to help explain how CDI helps with a wide range of concerns including with value-based care, length of stay, cost per case, case mix index (CMI), and CC/MCC capture rate. All of these assist the physician in optimizing his or her severity of illness (SOI) and risk of mortality (ROM) metrics. The new value-based care push by CMS will also be optimized through CDI. If they have managed Medicare patients – as we all do at this point – then CDI can help with HCC capture as well

Q: A lot of our denials are "short stay." What should we do about these denials?

A: Ask your medical director to review the chart and determine if the medical necessities of inpatient admission were met and have them call the payer for a peer-to-peer discussion. We get 89% of these denials approved at the peer-to-peer level, but this number falls off dramatically if you allow these to become full denials that require an appeal letter. It is much easier for your physician advisor to get these “short stay” denials overturned with a collegial conversation on the phone than with a letter.

Q: Do you have any recommendations for appealing a diagnosis denied due to clinical indicators when the discharge summary states possible or probable and treatment was the focus of diagnosis?

A: Review the record for the clinical criteria to support the diagnosis documented in the medical record. Remember the CMS 72-hour payment window allows 72 hours of outpatient data to support your inpatient diagnosis. For example, the ER (an outpatient setting) documentation may support the inpatient diagnosis made at the time of admission. Fight denials of conditions that were present in the ER, but improved at the time of admission. These are valid diagnoses according to the CMS 72-hour payment window.

In addition, review the record to see if the following conditions for a secondary diagnosis were met. The record will be: