Diagnosis Pitfalls to Look for When Seeking to Avoid Denials

A recent study from the healthcare solutions company Premier indicated that $19.7 billion is what hospitals and health systems are spending annually on handling and appealing denials. Yes, that is “billions,” with a “B.”

There are several reasons claim denials can occur, including but not limited to medical necessity, claim edits, pre-authorization, and others. Two reasons I’ve seen increasing of late are “clinically invalid diagnoses” and “coding errors due to inconsistent documentation.” With both of these, we see that “clinical documentation” is often at the center. Other times, we see payers using their own clinical criteria or their own interpretation of coding guidelines to support a diagnosis denial.

Now, granted, mistakes do occur, and they must be corrected in a timely manner once identified, but what I’m focusing on here is the ongoing payer denials that look into the clinical documentation and coding of a given diagnosis very differently.

To be valid, a diagnosis must cite the medical provider or physician conducting a face-to-face clinical examination and assessment of the patient, which is documented within the health record and at a minimum includes the following:

• Current Problem (Chief Complaint);
• Current Signs and Symptoms;
• Physical Examination;
• Review of Systems;
• Past Medical History;
• Past Surgical History;
• Family History;
• Social History, including the social determinants of health (SDoH);
• Allergies;
• Current medications;
• Results of any current tests (CBC, UA, Radiology, EKG, etc.); and
• Impression and Plan.

To ensure that there is accuracy and consistency in all the above areas takes detailed and specific documentation from the care team, especially the physician provider(s). Not only is it expected that the emergency room documentation correlates with the admitting history and physical, but these must correlate with the progress notes, consultations, and discharge summary. Let’s call this “consistency.” If the consistency is missing, then there could be a gap in determining the accurate ICD-10-CM code to assign, which is one key issue.

There is an ongoing practice from payors to deny the principal diagnosis and even secondary diagnoses if they are not listed in the discharge summary and/or final progress note, even if documented within the ED provider documentation and/or History and Physical, or even if documented on the progress note(s) except the final progress note. The payers say there is “inconsistent documentation to support the code,” and will thus request the ICD-10-CM code that was assigned and submitted be removed from the claim. Removing a particular diagnosis impacts payment, of course, but also alters the coded data picture of the patient encounter – and coding accuracy.

So, appealing is an appropriate and common practice for a hospital or healthcare system, often not once, not twice, but even three-plus times; yet this is often to no avail, not to mention time-consuming and costly.

The ICD-10-CM diagnosis coding comes from the “coding professional” reviewing all documentation and elements in the record. Then they apply and follow the Official Guidelines for Coding and Reporting and the American Hospital Association (AHA) Coding Clinic on ICD-10-CM. The coding professional is striving for accuracy and a true representation of the patient encounter.

So why are payers denying submitted ICD-10-CM codes on a claim? Often they assert that there is inconsistent or conflicting documentation: the emergency department (ED) and history and physical (H&P) will state one particular diagnosis and the discharge summary doesn’t mention it (or uses wording/language that is not as specific). For example:

ED and H&P documentation conclude that the patient has a right lower lobe pneumonia and the documented impression is “aspiration pneumonia.” During the four-day hospitalization, a swallowing evaluation was performed, and the documented conclusion was indeed that the patient had aspiration pneumonia. Thus, the patient was on aspiration precautions, along with appropriate antibiotics, and repeated chest X-rays, per two progress notes. There was the diagnosis of  “aspiration pneumonia” within two of the four progress notes as well. (All sounds good so far.) However, the discharge summary states the diagnostic impression of “pneumonia, right lower lobe, treated and improved.”

The payer has used algorithms and artificial intelligence (AI) to flag this claim, requested scanned copies be sent, and after their review to determine if all the diagnoses were accurate, they determined that the medical record (encounter) documentation was not consistent because the discharge summary didn’t state “aspiration pneumonia” specifically. The ICD-10-CM code assigned by the hospital was J69.0, Pneumonia due to inhalation of food and vomit. The payer denied this ICD-10-CM code of J69.0 and replaced it with J18.9 Pneumonia, unspecified organism. This impacted the encounter severity and acuity data for the patient and the hospital reimbursement. Thus the payer requested the difference be refunded to them due to inconsistent clinical documentation and coding inaccuracy.

Again, yes, the whole record must support the code. In fact, the Official Guidelines for Coding and Reporting state the following: “The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. “

This guideline does not say that the principal diagnosis or a secondary diagnosis needs to be documented on each page of provider documentation or specifically documented on the discharge summary. I agree that it is ideal and a best practice that the discharge summary contain the principal and secondary diagnoses; this, however, does not always happen, and thus the whole record is utilized. And yes, if there is truly conflicting documentation, there should be a query sent to the physician provider.

A quick aside: by “conflicting” I mean, for example, that a progress note says “COPD” and the discharge summary says “no pulmonary disease present;” that would be conflicting or even inconsistent.

But does the lack of a diagnosis only missing on the discharge summary really result in conflicting documentation? And does each and every provider document in the medical record need to state the specific diagnosis, every time? Or does the whole record stand as evidence of the given diagnosis?

The Official Guidelines also tell us the following: “These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings.”

Hospitals and healthcare systems are seeing a trend with some specific diagnosis denials. The following is a short list of common diagnoses that are often denied and/or requested to be removed from the claim (not an all-inclusive list):

          Sepsis (all ICD-10-CM codes representing “Sepsis”);

          Acute Respiratory Failure (including “Acute and Chronic”);

          Acute Kidney Injury (AKI or Acute Renal Failure);

          Encephalopathy (including “Metabolic”);

          Pneumonia (including “Aspiration”);

          Malnutrition (including “Severe Protein-Calorie”); and

          Alkalosis.

Payer denials also result from review of the clinical criteria for a particular diagnosis, with payors utilizing their own criteria to determine if a diagnosis is valid. This is another area that ultimately is impacting the ICD-10-CM code assignment. If the payor says that “their” clinical criteria were not met for a particular diagnosis and you don’t win on appeal, they ultimately remove that diagnosis from the claim, and usually it also gets removed from the patient record itself. This situation is one that takes more discussion than we have time for in this article but is another area to discuss within your facility or organization.

So, what to do about payor denials regarding consistency, as I described above? Well, continue to appeal, but also reach out to your payers and your contracting leadership, request a discussion of this situation, and be at the meeting on time. Discuss how the two (payer and hospital) entities in play can come to an agreement and revise the contracting language to fit the Official Guidelines for Coding and Reporting, meaning that the whole record counts in determining the ICD-10-CM code(s). Taking this step might help in decreasing payor denials and also improve ICD-10-CM final accuracy. Also, arrange for an audit of, say, 50 inpatient records, and compare the ED, H&P and discharge summary diagnoses that are documented. Sometimes this can indicate an issue with a particular provider (i.e., hospitalist, resident, DO, NP, etc.), and you can have a positive discussion with them regarding their documentation. Sometimes the provider won’t document a diagnosis again after it has resolved, especially if it was present for the first 24-36 hours only and then is gone, resulting in it not being stated in the discharge summary.

So, working to improve documentation and coding accuracy to help decrease payer denials will take some time, but ultimately prove worth the effort – so don’t wait, start now.

Programming note:

Listen to senior healthcare consultant Gloryanne Bryant report this story live during Talk Ten Tuesday today, 10 Eastern with Chuck Buck and Dr. Erica Remer.