Warding off Clinical Validation Denials with Improved Documentation

Clinical validation (CV) denials are plaguing us lately. When I work on projects entailing medical record review, I must admit that it is not unusual for me to agree with the payer. However, if a legitimate diagnosis is denied, the blame often stems from the documentation.

I recently had an epiphany as to a methodology for providers to put “mentation” into their documentation and ward off denials.

I recommend a macro in the setting of sepsis. It goes like this:

Sepsis due to (infection) with acute sepsis-related organ dysfunction as evidenced by (organ dysfunction/s).

If the coder can’t identify an infection, either the provider is not documenting it properly (e.g., “decubitus ulcer” is not equivalent to “an infected decubitus ulcer with surrounding cellulitis”), or there is no sepsis. There has to be an infection in order to progress to sepsis.

If the practitioner can’t provide any organ dysfunction in that field, either they missed the organ dysfunction (organ dysfunction is not only SOFA, Sequential Organ Failure Assessment), there is no sepsis, and/or there is increased risk of denial.

When I thought about it, I realized that this sentence composition works for lots of conditions, and could be prophylactic against other CV denials:

• Acute-on-chronic hypoxic and hypercapnic respiratory failure due to severe exacerbation of chronic obstructive pulmonary disease (COPD) as evidenced by oxygen saturation in mid-80s and increased CO2 with pH of 7.32. Placed on BiPAP, steroids, nebulizers, and antibiotics. Will monitor closely.
• Pneumonia, probably aspiration, as evidenced by fever, cough, shortness of breath, elevated WBCs, and RLL infiltrate. Was known to have vomited in NH two nights prior. Being treated with antibiotics and supplemental oxygen.
• Severe malnutrition due to cachexia from pancreatic CA as evidenced by BMI 14.7, loss of weight of 10 percent in last month, and muscle wasting. Appreciate dietitian consult. Will implement appetite stimulation and dietary supplementation.

The elements of this construction are:

1. The condition being diagnosed affirmatively or uncertainty (e.g., possible, probably, suspected, likely, etc.);
2. The etiology, using linkage (e.g., from, due to, caused by, as a result of, etc.);
3. The manifestations (clinical indicators); laboratory, imaging, or other supporting evidence (e.g., as evidenced by…); and
4. Plan of treatment.

Maybe they should think about it as: condition…due to…as evidenced by…treated with…

The provider doesn’t need to do this every time they are discussing the diagnosis (i.e., it doesn’t need to be copied and pasted from day to day). It needs to be done upon the initial diagnosis. From that point on, the practitioner just needs to document whatever is relevant that day. Is it getting better? Did some of the manifestations resolve? How is the plan changing? Did the diagnosis evolve from uncertain to definitive? Having multiple mentions of the ongoing condition will demonstrate that it is a clinically valid and significant diagnosis. A best practice is to have it reappear in the discharge summary as well.

Teach this to residents and onboarding providers, and when you are educating service lines on best practice. If you give feedback, use this construction to model good documentation practice.

Some of you might be thinking, “but the payers have specific, ridiculous, unattainable criteria that they demand for the diagnosis of that condition.” That is a different problem. If that is baked into your contracts, address it. If they are just quoting silly criteria to justify unjust denials, fight it. Good documentation doesn’t completely eliminate denials, but it does help the person responsible for appeals, and helps me assess clinical validity when I perform audits.

Have your provider practice good medicine and produce good documentation, expressing what they thought and why they did what they did. It won’t make all denials go away, but it should decrease the number of them. As a bonus, this pattern of construction may help the clinicians organize their thoughts and communicate their thought process to their colleagues.

And that might just improve the quality of care delivered to your patients!

Programming note:
Listen to Dr. Erica Remer live as she cohosts Talk Ten Tuesday with Chuck Buck at 10 Eastern.