Appealing Clinical Validation Denials is a Team Effort

Clinical validation denials continue to climb.

When payers issue clinical validation denials, they challenge diagnoses documented in the chart by the providers caring for the patient. Sometimes, it’s not simply the validity of diagnoses in question, but whether coding rules were violated. 

This being the case, assessment and subsequent potential appeal of these denials optimally involve four subsets of the hospital team: a) clinical documentation improvement (CDI), b) coding, c) contracting, and d) physician advisors.

It’s extremely important to collaborate with your contracting office and understand precisely what is present within each payer’s contract when it comes to appeals. Timeframes, methods, and opportunities for escalation should be clearly identified and understood by the team. At my health system, once we developed a working relationship with folks in contracting, a whole new strategy for appeals opened up to us.  Here’s how we do it:

When a denial is first received by the coding team, the original coder contacts the original clinical documentation improvement specialist (CDIS) involved in the case. The CDIS is asked to review the denial letter and the chart with regard to the denied diagnosis. If the diagnosis has specific standard criteria set into place by the health system, these are also reviewed. In scenarios such as protein-calorie malnutrition, the supervisor of dietary services may be consulted for a review. From there, the CDIS provides a clinical recommendation to the coder on whether to appeal or accept the denial.

In the event of a second-level appeal or telephonic appeal with a third-party reviewer (which are contracted by some payers), our CDI supervisor becomes involved. She reviews all denial letters, all appeals to that point, the patient’s chart, and any electronic communication/collaboration between the CDIS and coder before the initial claim was dropped. The entire medical record is re-reviewed, looking specifically for how the diagnosis is clinically supported with lab values, diagnostic testing, and consistent documentation within the record. Any possibly conflicting documentation is noted and assessed, and internal diagnosis criteria are compared to the clinical elements captured within the chart. 

The CDI supervisor creates a spreadsheet of her findings, which includes the following:

  • Demographic patient information
  • The diagnosis in question
  • A recommendation to appeal the denial or not
  • Clinical information within the chart, which validates the diagnosis and informs the decision on whether to appeal

Three to five days prior to a telephonic appeal, this spreadsheet is shared with me, as the physician advisor, the supervisor of the coding team, the coding team lead, and the coding/HIM (health information management) director perform review and further preparation.

On the coding side, the coding team lead prepares for telephonic appeals by reviewing the original denial that started the whole process, in addition to our initial appeal. Another assessment of the electronic trail of collaboration between the initial coder and initial CDIS is also completed. 

For denials specifically related to coding, the coding team lead and the original coder of the claim create a comprehensive argument for the appeal based on the applicable coding rule. Usually, in these instances, little input is needed from the CDI supervisor or me unless the conversation turns clinical in regard to the nature of the patient’s medical condition. 

In some instances, cases that were appealed or even secondarily appealed by the coder are found by the CDI supervisor (and/or me) to lack the level of conviction needed to further support the diagnosis in question. My coding supervisor remarked that this is expected, as some cases simply are borderline in nature and “deserve the benefit of clinical insight and experience.” 

During the telephonic appeal, I, the CDI supervisor, the coding team lead, the coding supervisor, and a member of the contracting team are on the line. I summarize the clinical findings within the chart and supporting criteria met for the denied diagnosis, based on the information found in the spreadsheet. As needed, the CDI supervisor assists by providing further detail about lab values, health system criteria for the diagnosis in question, and any other clinical support found in the electronic medical record. Usually, there is also a conversation between our team and the third-party reviewer’s medical director about the case, looking at it from both vantage points. Rarely does the situation simply constitute us stating our case without any further discussion.

Since starting this process in 2017, we have appealed 130 cases telephonically, with 55 percent successfully overturned before the phone call, during the phone call, or following tertiary review by the payer’s medical director. We’ve lost 16 percent, and in 30 percent of the cases, the CDI supervisor and I did not feel that we could adequately defend the diagnosis, so we conceded the denials. At the current time, 15 percent of our cases are still pending tertiary review.

As the number of clinical validation denials continues to climb, the number of our appeals has escalated proportionally. We have stuck to our guns with this tedious and time-consuming process, and participate in scheduled telephonic appeal sessions at least once a month. On occasion, we are notified that all or most of our upcoming cases to be discussed have had their associated denials overturned before the call even happens.

I want to extend my sincere thanks to my colleagues at Prohealth Care, the supervisor of clinical documentation improvement, Kerry Termaat, and the coding team lead, Bridget Meissner, for detailing their individual processes for me in preparation for writing this article. Both requested that I emphasize the notion that this process would not work without strong cooperation and respect between the CDI team, coding team, and myself, as the physician advisor. Additionally, this kind of collaboration takes not only talent and leadership, but also a considerable amount of time. Try to make it apparent to your hospital’s leadership that for this process to work smoothly and produce favorable results, all three must be cultivated.


Program Note:

Listen to Dr. Juliet Ugarte Hopkins report this story on Talk Ten Tuesday at 10 a.m. Eastern.

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Juliet B. Ugarte Hopkins, MD, CHCQM

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the RACmonitor editorial board, and a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and contributes to ICD10monitor.

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