According to an Experian Health Data report, the rate of insurance denials is increasing, up to between 10 to 15 percent. Anecdotally, hospitals can confirm that increase. Clinical validation has added a twist to insurance denials.

The most frequent topics I see in clinical denials are acute (on chronic) congestive heart failure, sepsis, toxic/metabolic encephalopathy, hyponatremia, acute respiratory failure, and severe malnutrition. While the physician may document these diagnoses, the clinical information behind the documentation must support them.

Each diagnosis must be consistently documented. If not, then a post-discharge query may resolve any ambiguity.

For acute congestive heart failure, insurers are looking for a positive chest X-ray, leg edema, and treatment with IV diuretics. The history and physical (H&P) should show evidence of edema. The medication administration record should show the use of IV diuretics (e.g., Lasix, Bumex, etc.).

For sepsis, there is a quandary regarding the criteria used to determine the diagnosis – Sep-2 or Sep-3. In some cases, I have seen a facility continuing to utilize SIRS (systemic inflammatory response syndrome). Insurers want facilities to utilize their criteria to determine sepsis. A denial will typically include reference to the payer’s criteria. Each facility should utilize the payor’s criteria when appealing the denial. In general, there should be a local infection with evidence of a systemic infection.

Toxic/metabolic encephalopathy is a condition in which the patient suffers from a change in alertness or has abnormal cognition. An electroencephalogram (EEG) may support this diagnosis but is not mandatory. Consistent documentation of improvement in the patient’s mental status is important. There should also be documentation of the source of the toxic/metabolic encephalopathy, if possible. The warning would be that mental changes are involved in other situations, such as appropriate response to correct use of a medication/anesthesia.

Another target for denial is hyponatremia. The insurer will review the patient’s sodium levels. The level payers often quote as being significant is 130. Remember that the changes in the ICD-10-CM Official Coding Guidelines state that to report the additional diagnosis, it must be clinically significant.

Acute respiratory failure is another target for denials. These cases will be reviewed for respiratory rate higher than 24 and documentation of tachypnea. Other symptoms include work of breathing or dyspnea. The treatment should include supplemental oxygen at an elevated level, Bi-PAP, or the use of a mechanical ventilator. It should be noted that the use of a ventilator is not required.

According to Focus for Health, approximately 40 million Americans suffer from malnutrition. Severe malnutrition is a major complication/comorbid condition (MCC) and is a target for clinical validation. Documentation of cachexia, muscle wasting, and unintentional weight loss should be clear. There should be evidence of treatment for these cases, such as nutrition consultation, tube feeding, or protein shakes.

Another focus for inpatient hospital coders is cases with one comorbid condition/complication or one major comorbid condition/complication. These conditions affect the MS-DRG assignment, and payers will try to disprove them to reduce reimbursement.

It is important for coders and clinical documentation specialists to work as a team. A team works together to accomplish a common goal. This team must be proactive, when possible. It is best to delay the submission of a claim by awaiting a response to a clinical validation query rather than fight the payer denial.

Print Friendly, PDF & Email

Laurie M. Johnson, MS, RHIA, FAHIMA, AHIMA Approved ICD-10-CM/PCS Trainer

Laurie Johnson is currently a senior healthcare consultant for Revenue Cycle Solutions, based in Pittsburgh, Pa. Laurie is an AHIMA-approved ICD-10-CM/PCS trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences. Laurie is a member of the ICD10monitor editorial board and is a permanent panelist on Talk Ten Tuesdays

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 SDoH Update: Navigating Coding and Screening Assessment

2024 SDoH Update: Navigating Coding and Screening Assessment

Dive deep into the world of Social Determinants of Health (SDoH) coding with our comprehensive webcast. Explore the latest OPPS codes for 2024, understand SDoH assessments, and discover effective strategies for integrating coding seamlessly into healthcare practices. Gain invaluable insights and practical knowledge to navigate the complexities of SDoH coding confidently. Join us to unlock the potential of coding in promoting holistic patient care.

May 22, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →