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I often hear auditors and coding leaders say that their physicians are pretty good at listing rationale for their diagnoses of sepsis, acute respiratory failure, and encephalopathy. However, commercial insurance continues to deny their claims.

They are very frustrated – and wondering if the new ICD-10-CM guideline will help. What they are referring to is, of course, one of the new guidelines added for the 2017 fiscal year, effective Oct. 1, 2016. It is guideline No.  19 in Section I.A., Conventions for the ICD-10-CM, and it states: 

“19. Code Assignment and Clinical Criteria

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

I believe one intention of the Centers for Medicare & Medicaid Services (CMS) in adding this guideline is to assist us when we get denials based on a lack of clinical indicators. It is really difficult to say right now whether the guideline will actually help. Ideally, it should, but as you probably know, there are current guidelines that are ignored by third-party reviewers and payers. It is an extremely frustrating situation, and one that many facilities face. 

The best defense is a good offense, and by that I mean continuing to work with providers on their documentation of these conditions and the clinical support that they see in their patients. Ultimately, payers are doing everything they can to reduce their payments. Because of that, what I call bulletproof documentation is key.

One thing to keep in mind is that in many cases, just simply documenting a specific diagnosis for a patient may not be enough. Usually the patient would need to demonstrate that they are ill enough to be diagnosed with sepsis, acute respiratory failure, or encephalopathy.  These patients should have clear documentation supporting such serious and life-threatening illnesses. 

I think the surge in sepsis documentation started a few years ago, when there was a big push by infectious disease departments in hospitals across the country to give their physicians the idea that clinically speaking, a patient need only meet two of the four criteria to actually be diagnosed with sepsis.

While the intentions may have been good in getting that word out to physicians, the result was that nearly everyone with a fever and tachycardia was being diagnosed with sepsis. In response to this, with sepsis being a life-threatening condition, most short-stay hospital admissions with a diagnosis of sepsis became a target for third-party payer and Recovery Auditor Contractor (RAC) audits. The rest is history. 

There’s a similar issue with acute respiratory failure. I frequently see accounts of patients being intubated for airway protection, and inevitably at least one doctor – maybe more – then starts documenting acute respiratory failure.

I have participated in task forces with chief physicians of these departments, and once specifically heard a chief pulmonologist say that he had providers documenting acute respiratory failure in patients with shortness of breath who were treated with 2L nasal cannula oxygen – and he correctly noted that this is not even close to what would be needed for a respiratory failure diagnosis. In light of all this, there definitely is a problem with over-documentation of these conditions.

But that’s not to say that there aren’t patients out there who truly have these conditions. 

This problem has many facets – some of it is the RACs and third-party auditors using clinical criteria to reverse DRG charges inappropriately. Some of the problem is physicians not buying into the importance of their documentation. Some of the problem is local coverage determinations (LCDs) and national coverage determinations (NCDs) severely limiting the symptoms or diagnoses a patient must exhibit to get diagnostic tests that some of them desperately need (and maybe sometimes the physician stretches the patient’s symptoms to get those tests for them).  

If I were a director of coding or compliance, one thing I would do is consider getting some physician champions in those departments in order to begin and continue dialogue with their physicians on these issues, really driving home to them how important it is that their documentation paints the severity-of-illness picture as accurately as possible for each patient. Is this idealistic? Maybe. But one of the solutions to this problem is definitely documentation improvement and physician education.    

There are no guarantees or absolutes with this new guideline, and I think that ultimately, we will have to watch and see what happens.

I would, however, absolutely use it in defense of denials, when appropriate.


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