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EDITOR’S NOTE: This is the second portion of a two-part series of articles highlighting detailed examples of two challenged denials that followed third-party healthcare audits.

In our second example, a 73-year-old female presented to the hospital with syncope following a fall at a physician office:

  • The provider assigned I67.1 (Cerebral aneurysm, nonruptured) as the principal diagnosis. Upon review of the documentation provided, I67.1 was not supported as the principal diagnosis. Based upon review of the provided medical records, the physician noted that the patient was admitted due to spinal contusion with fractures after falling at a physician office. When a patient is admitted with spinal cord injury and fracture, the spinal cord injury is assigned as the principal diagnosis. Furthermore, the abdominal aortic aneurysm was noted as an incidental finding noted after admission. Per the guidelines referenced below, the principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” Based on diagnostic workup and therapy provided, S14.0xxA (Concussion and edema of cervical spinal cord, initial encounter) is the condition that most closely meets the principal diagnosis definition. Also, per instructions in the ICD-10 Tabular List of Diseases and Injuries referenced below, when an encounter is for a vertebral fracture associated with a spinal cord or spinal nerve injury, there is an instructional note to code first any associated spinal cord or nerve injuries, followed by the appropriate code(s) for vertebral fracture. In accordance with this reference and physician documentation provided, I67.1 has been replaced with S14.0XXA as the principal diagnosis.
  • This results in a change in DRG from 268 to 041.
  • Reference: ICD-10-CM Official Guidelines for Coding and Reporting, Section II. Selection of Principal Diagnosis; ICD-9-CM Coding Clinic, Fourth Quarter 2004 Page 137, Acute bronchitis with acute asthma. ICD-9-CM Coding Clinic, Fourth Quarter 1990 Page 5-6 UHDDS reporting of procedure codes – guidelines. ICD-10-CM Official Guidelines for Coding and Reporting, Section III. Reporting Additional Diagnoses.
  • This medical record review was performed under the supervision of the medical director.
  • Coding Response:
    • Disagree with Denial
      • The patient arrived via EMS from another care facility for the syncopal episode with C5 vertical fracture and C6 pedicle fracture. However, patient has multiple medical problems listed in the history and physical on _____ by Dr. _____, MD:
        • Comminuted nasal fracture
        • Macrocytosis
        • Hypertension
        • CAD
        • History of bladder outlet obstruction
        • Chief complaint included some radicular pain in the RLE
      • H&P review of systems (ROS) has contrary information related to diagnoses, as each ROS is listed as “negative.”
      • Progress Note _____ by _____, NP shows in exam that patient “thinks he is at a hotel or is trying to get to go to Walmart,” and states patient is “slightly confused.” Under plan, she orders brain CT for confusion and follow-up.
      • Consultation _____by _____, NP states “will obtain MRI 2/2, CT results and patient complaints of some radicular complaints in LUE initially.”
      • ROS is contrary, with “negative” results.
      • CT brain results on _____ by Dr. _____, MD states “clinical history: status post fall, altered mental status, confusion.”
      • Progress Note _____ by _____, MD, shows “subjective pt aao confused.” Also, ROS “Neurologic: Confusion, Psychiatric:  Anxiety.” Physician provides diagnoses of agitation confusion, and fact that patient shows a 7.5 cm diameter abdominal aortic aneurysm.
      • Vascular consult _____ by _____ FNP is for the “incidental finding of the AAA.” Patient is diagnosed with AAA and also thrombocytopenia; nursing personnel are instructed to monitor any abdominal, chest, or back pain symptoms.
      • Progress Note _____ by Dr. _____ MD lists multiple confirmed problems for this patient, such as:
        • Acute confusion
        • Hyperlipidemia
        • Left bundle branch block (RBBB).
      • Dr. _____ MD notes patient is still confused, is not alert and oriented, and that patient is going to “need surgery; he is high risk.”
      • Consultation _____ by _____ PA and authenticated by Dr. _____ MD shows patient is in AFIB, unable to obtain ROS, patient has a history of left heart cath, patient is in acute confusion with garbled speech, syncope is from an unknown etiology, patient is moderate-high risk for pending surgery.
      • Progress Note _____ by _____ NP notes continued confusion by patient though he is now sedated. Diagnosis of spinal cord contusion.
      • Progress Note _____ by Dr. _____ MD shows patient is still confused and now on restraints due to pulling on tubes and getting out of bed. Patient’s AFIB has been converted and per cardiology, no intervention for the cerebral aneurysm yet per vascular, patient now has additional diagnoses of constipation and dysphagia and now per telemetry sinus rhythm tachycardia. A cardiology consult has been ordered.
      • CTA of brain on _____ shows “anterior cerebral aneurysm infarct, which extends to and involves both middle and posterior cerebral arteries. There is also aneurysmal dilatation of the brainstem midbrain. As no evidence for active leakage. Approximately 3.8 cm below the level of cerebellar.”
      • Progress Note _____ by _____ NP requests risk stratification for surgical planning.
      • Vascular Progress Note by _____ FNP lists cerebral aneurysm, HTN, and acute confusion as the working diagnoses, with plans related to treatment and probable surgery for the cerebral aneurysm. Patient’s mentation has changed, and patient is now alert and oriented.
      • Progress Note _____ by _____ NP confirms plan for patient to begin standing, and that patient has been cleared for surgery for the cerebral aneurysm and remains asymptomatic from the spinal cord contusion.
      • Progress Note _____ by _____ FNP states patient is scheduled for endovascular repair of cerebral aneurysm on tomorrow (_____).
      • Progress Note _____ by Dr. _____ MD confirms patient is cleared for vascular procedure and is asymptomatic from the spinal cord contusion.
      • Progress Note _____ by _____ PA recommends loop recorder procedure for _____.
      • Vascular Procedure OP Note _____ Dr. _____, MD repairs the cerebral aneurysm.
    • We disagree with this RAC denial on this account. The patient’s fractures were not seen as addressed surgically during this admission. However, the patient did have the cerebral aneurysm repaired and a loop recorder inserted for their tachycardia condition.
    • The official coding guidelines state that “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.”
    • Reference: ICD-10-CM Official Coding Guidelines Section II.C – Two or more diagnoses that equally meet the definition of principal diagnosis, ICD-10-CM Official Coding Guidelines Section I.A.19 – Code assignment and Clinical Criteria
    • ICD-10-CM Official Coding Guidelines Section III. Reporting Additional Diagnoses

Results are pending on the above item, which we recommended an appeal on. 

However, what is apparent to me is that the RAC audit staff did not review all available information within the medical record, and in my opinion, took a very slanted or biased view of the information and formulated a decision that was beneficial only to the RAC and Medicare.

I could share multiple other examples in which:

  • The payer apparently did not review detailed information in the medical record, though they state in their denial letter that they did.
  • The payer tries to utilize Official Coding Guidelines, or instruction of some kind or another, to deny a claim based upon clinical information and documentation from healthcare providers who are licensed to diagnose and treat various illnesses and injuries – either by way of diagnostic, therapeutic, or surgical means – and the reasoning, justification, and decision-making for those items are owned wholly by the healthcare provider and not by coding staff.

We have claims for which we agree with payer denials. Sometimes, yes, the documentation does not support how the case was coded, or there were coding errors to be learned from within the denial scenario. But with the ongoing and ever-increasing push for automated review by electronic means for claims analysis, the challenges will continue and expand, making the lines between coding and clinical documentation improvement (CDI) blurred. And the ability to provide clean claims and receive timely payment on high-dollar, complex cases will become more and more rare.


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