Radio Recap: Brundage discusses denials and physicians communication

March 21, 2017

CDI Blog - Volume 10, Issue 34

Editor’s Note: Timothy Brundage, MD, CCDS, medical director of Brundage Medical Group, LLC, in Redington Beach, Florida, presented on the January 11, 2017, installment of ACDIS Radio. The title of the program was “Denials and effective physician communication.” This Q&A was developed from conversations during that session. Should you have any questions regarding the material, please reach out to Brundage at DrBrundage@gmail.com.

Q: Have you encountered denials based on “Late Entry” where CDI query response was received after discharge?

A: This is a technique by the auditor to deny a reasonable diagnosis. The CDI team can query the physician up to the time of the final coding. Getting the query response and therefore 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 that they don’t care about CDI, they’re not interested, or they refuse to hear education. How do we get through to them?

A: Leverage the influence of your physician advisor and/or chief medical officer to encourage them and share the value of CDI efforts with the rest of the medical staff. This helps both the facility and the physicians with value based care, length of stay (LOS) metrics, cost per case, case mix index, as well as CC/MCC capture and DRG shifts. Improving these aspects, in turn, help the physician in optimizing severity of illness (SOI) and risk of mortality (ROM) metrics. CDI also helps with the various measures included in CMS’ value based purchasing. Physicians who have managed Medicare patients (we all do at this point), benefit from record reviews focused on specificity related to the capture of diagnoses for hierarchical condition categories(HCC) as well.

Q: Can the CDI team do anything to help prevent short-stay denials?

A: Ask the medical director to review the chart of the denied claim to determine if the medical necessity of inpatient admission was met. If the medical director or CDI physician advisor believes medical necessity was met, have him or her reach out to the auditor over the phone for a peer-to-peer conversation before drafting an appeal letter. We get 89% of soft 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. Your physician advisor can call and get these overturned with a collegial conversation much easier than a letter can.

Q: Do you have any recommendations on appealing a denied diagnosis due to clinical indicators, but in the discharge summary it states “possible” or “probable” and treatment was the focus of diagnosis?

A: Review 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 emergency department (ED) (an outpatient setting) documentation may support the inpatient diagnosis made at the time of admission. Fight denials of conditions that were present in the ED, 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: