One Claim with Multiple Denials Calls for Smart Defense

By Denise Wilson MS, RN, RRT
September 27, 2017

CERT claim review highlights need for strategic approach.

How do you handle your appeals when there is more than one issue being denied? For example, if the payer denies both the medical necessity of the level of care as well as the coding of a procedure, what strategies should you employ to challenge it?

When two issues are being denied, the appeal strategy first of all will depend on whether the denials were issued at the same time. If the denials were issued at the same time (that is, within the same decision letter), then both issues should be appealed in the same appeal letter. This typically requires the collaboration of both a clinician and a coder to develop one cohesive response that addresses both issues.

If the two issues were denied at different times (that is, two separate decision letters were issued with different dates), then each issue should be treated as a separate denial with a separate appeal, even if the appeal time frames overlap. The obvious logic behind this is that the time frames for appeal will be different for each denial, depending on the date the denial was issued. Thus, the appeal for each issue should be filed separately so that time frames can be more easily managed.

Just recently I was reviewing a decision letter from the Comprehensive Error Rate Testing (CERT) contractor on the issue of a TAVR – that is, a trans-catheter aortic valve replacement, which is currently on the CMS inpatient-only list.

Essentially, the CERT contractor was reviewing the claim for this nine-day hospital stay to ensure it met the criteria for medical necessity, as outlined in the National Coverage Determination for this procedure. The contractor reviewed the documentation to ascertain whether certain elements, such as the required preoperative evaluation by two cardio-thoracic surgeons, were present in the record. Unfortunately, in this case, the required evaluations were not present, and the CERT denied the medical necessity of the procedure, resulting in down-coding of the DRG.

What I found interesting, though, was that the CERT went to great lengths to explain that the inpatient hospital admission for this inpatient-only procedure was in fact reasonable and medically necessary. The reasoning the CERT provided was that this patient’s intraoperative and postoperative complications included a need for a blood transfusion, BiPAP, monitoring of thrombocytopenia, and treatment of increased blood pressures.

So let’s imagine for a moment that the CERT contractor reviewed the medical necessity of a procedure that was not on the inpatient-only list. And let’s imagine that in this case, the patient experienced complications that warranted an inpatient admission, following the two-midnight rule. And let’s further imagine that in its decision letter following its review, the contractor issued a statement on the medical necessity of the inpatient admission, deeming it to be reasonable and medically necessary.

I would strongly encourage a provider to flag a case such as this as having been reviewed and approved for the appropriate level of care, even if that was not the original purpose of the review. Should this case ever be requested by any other CMS auditor for level-of-care review, I would certainly argue that it is no longer eligible.

And finally, I would be certain to reiterate in my appeal of the medical necessity of the procedure that the CERT contractor had deemed the inpatient admission to be reasonable and medically necessary.

The CERT denial letter and your appeal letter will serve as proof that this case was already reviewed for level of care, should any other CMS auditor attempt to pull it for review.

TAGS: Appeal, Claims, CMS, Denials

Denise Wilson MS, RN, RRT

Denise Wilson is a Senior Vice President at AppealMasters and serves as President of the Association for Healthcare Denial and Appeal Management (AHDAM). She also provides ongoing education and expert knowledge to internal and external clients on commercial and Medicare denials and appeals via web-based seminars, onsite training, written materials and one-on-one consultations. She created and trained an appeal-writing team, which has grown to a staff of more than 70 nurses, physicians and coders.

Featured Webcasts

2026 IPPS Masterclass: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.

August 12, 2025

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025

Open Door Forum: Fraud Detection in Healthcare – Spot Red Flags, Avoid Liability

Fraud convictions don’t just punish a few bad claims; they can wipe out years of reimbursements. Don’t wait for an audit to learn the rules. Join Frank Cohen, MPA, for a live Q&A on spotting red flags, avoiding liability, and protecting your practice. Register now and bring your questions!

July 23, 2025

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025. Register today and be a part of the conversation!

July 16, 2025

One Claim with Multiple Denials Calls for Smart Defense

Denise Wilson MS, RN, RRT

Related Stories

Embrace Your Physician Advisors’ Potential

Leave a Reply

Featured Webcasts

2026 IPPS Masterclass: Final Rule Update with Expert Insights and Analysis

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

Trending News

Navigating Gender-Affirming Care in a Shifting Legal Landscape: Documentation, Coding, and Compliance Strategies

Unpacking the RUC Time Study: Where Physician Work Valuation Meets Compliance Risk

A Troubling Disregard for the Law

One-on-One Time and a Light Touch: Tips for Conducting Interviews on Legal Matters

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

Open Door Forum Webcast Series

Open Door Forum: Fraud Detection in Healthcare – Spot Red Flags, Avoid Liability

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Trending News

“I’ve Never Heard This Before” – How Closed and Open Minds Can React with the Same Words

CMS Crackdown on Medicaid Coverage for Undocumented Patients Raises Red Flags for Hospitals, Case Managers, State Programs

Content, Schedule Announced for New RACmonitor/ICD10monitor Webcast Series

What Coders Need to Know: Anticoagulant versus Antiplatelet – Coding Considerations

Stay Connected

News

Account

Info