Book excerpt: Crafting a clinical validation appeal

by Cheryl Ericson, RN, MS, CCDS, CDIP and Cathy Farraher, RN, MBA, CCM, CCDS

From the outset, crafting appeals for clinical validation should follow the format established by the facility denials management team for any other appeal. Best practice for the opening paragraph is to set an appropriate tone and rapport by addressing the organization, briefly stating the reason for the appeal, and restating the reason for the claim denial. At the end of that paragraph, outline the facility’s stance as to why the denial should be overturned.

Ensuing paragraphs need to provide the related patient identifiers to help the auditor identify the claim. It should also include a complete description of the patient and their medical history to illustrate the patient’s complexity and provide a human perspective to the patient’s needs at the time of the hospitalization.

This section should also include all complications that may have occurred as well as all possible complications that could have occurred. The idea is to concretely demonstrate the seriousness of the patient’s clinical situation. Additional sections of the appeal need to include point by point any reasoning behind the appeal. Use a single paragraph for each point of rebuttal within the appeal.

If creating a clinical status (for inpatient admission) appeal, one paragraph should also be dedicated to reviewing all applicable Medicare, Milliman, and/or InterQual guidelines and how the patient met or surpassed those requirements and needed to be admitted to the hospital for care.

The last paragraph should be brief and summarize all the reasons the facility clinical documentation and code assignment were/are accurate and why the denial is inappropriate. Finally, professionalism comes into play in the closing sections, as the letter should thank the agency for their considerations and establish a set of suggested outcomes and timelines for a positive resolution to the discrepancy.

There is no magic bullet to prevent medical necessity denials. Not all clinical validation denials can be prevented.

CDI efforts should focus on educating providers to demonstrate their medical decision-making, especially when the provider arrives at a conclusion (i.e., diagnosis) that cannot be inferred from the health record. Basically, if the patient has an “atypical presentation” for a particular condition, the provider should “think in ink” so others can arrive at the same conclusion based on the same evidence.

Editor’s note: This article is an excerpt from Ericson and Farraher’s book, Clinical Validation Reviews for CDI Professionals.