Guest post: Location, location, location

by Howard Rodenberg, MD, MPH, CCDS

Ever had a word that you’ve mispronounced your entire life? Of course, all of us have those as a kid. In my younger day (you know, last Thursday), it was the word chaos, which I was convinced sounded like “chowse,” and doubt, which I simply knew had to be pronounced with the “b” intact. Fortunately, a fine public-school education rid me of these issues, but a few leftovers remain. One of them was the word “realtor,” which for years I pronounced “re-la-ter.” That was before I worked with an agent who would always knock of the door of a home she was showing and yell, “KNOCK KNOCK REAL-TOR,” presumably to send squatters scurrying out the back. Now I say “real-tor” with smug satisfaction that I can use the term like a professional.

I was thinking about my realtor the other day as I was going through the latest round of private payer claim denials. While I’m continually frustrated by the denials process, I must admit to a grudging admiration for the sheer creativity of the reasons they come up with to reject a claim. The latest twist has everything to do with the mantra of real estate: Location, location, location.

This new trend seems to revolve around the idea that if something can be done at home, then it invalidates the hospital-based claim. In one case example, a patient presented with dyspnea, was diagnosed with acute hypoxic respiratory failure, and treated with oxygen per nasal cannula. The denial letter indicated that one of the criteria for rejecting the diagnosis is that “oxygen supplementation via nasal cannula is often provided in the home and is not considered, in itself, a treatment for acute respiratory failure.”

I’ve previously discussed newer recommendations for oxygen therapy and how they relate to the diagnosis of acute respiratory failure in the May/June 2019 edition of the CDI Journal. For this discussion, suffice it to say that to avoid the dangers of hyperoxia, oxygen therapy should focus on achieving a target oxyhemoglobin saturation of 92%-93% (slightly less in patients with chronic obstructive pulmonary disease). This target is independent of the amount of oxygen used or the mode of delivery, rendering older definitions of acute respiratory failure that require these specifics obsolete. In the context of these newer definitions, the treatment of acute respiratory failure may well encompass oxygen administration via nasal cannula as the most appropriate care if the target values can be obtained by this means alone.

(As an aside, it should be noted that we’re not addressing the use of heated, humidified, high-flow nasal cannula, which really is exclusively hospital-based care.)

Can oxygen be administered at home by nasal cannula? Of course it can, and it’s often used in the home for patients with chronic respiratory failure. But the argument that oxygen can be administered at home misses the point. There is nothing inherent about a location that verifies or invalidates a diagnosis or procedure. If someone goes into cardiac arrest, is it not cardiac arrest because it happened outside of the hospital? Similarly, is the patient in cardiac arrest not really in cardiac arrest because the paramedics performed CPR at home rather than in the ED? The fact that a particular treatment can be administered at home in no way invalidates the patient’s need to be in the hospital when viewed within the larger context of the case.

I’ve seen the same sort of logic applied—or misapplied—to cases of malnutrition. Last week I reviewed a second-level denial (our first appeal was rejected) for a patient diagnosed with severe protein-calorie malnutrition using the American Society of Parenteral and Enteral Nutrition (ASPEN) criteria. One of the new comments in this second denial explained that “oral nutrition supplements, which are typically over-the-counter, are often and routinely provided in the home setting and does not clinically equate with acute inpatient treatment for severe protein-calorie malnutrition.”

Similar to the case of acute respiratory failure, when caring for patients with malnutrition one wants to use the least invasive means possible to achieve therapeutic goals. In these cases, that would mean that if the patient is able to tolerate oral feedings, oral supplements would be preferred over feeding tubes or total parenteral nutrition, both of which carry significant risks. Once again, noting that a particular therapy is available at home does not invalidate the diagnosis. To carry this to its extreme, one might contend that a diagnosis of pyelonephritis is invalid simply because patients can receive oral antibiotics and Tylenol at home.

Cleary, these location-based arguments used to refute a diagnosis hold no water. But they bring up a larger issue as well. Clinical cases should be reviewed in their entirety to establish the validity of a diagnosis. Physicians use the entire patient encounter, as well as their judgement, experience, and the current state of medical science, to inform their diagnostic and therapeutic efforts. It seems reasonable to ask that just as we do so in our process of clinical validation, the “gestalt” of the record also be respected by the outside world. But when the broad view is sacrificed for pettiness, it’s our duty to illustrate these errors in thought and practice as we advocate for patients and their caregivers.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.