Shore up the medical record and your hospital with these denials-busting documentation strategies

By Brian Murphy

If you’re a CDI specialist these days, odds are you will be involved in denials. According to the 2022 ACDIS Industry Overview Survey released in February, 68% of respondents indicated that they were involved in the denials or appeals process—10% higher than in 2021 (1).

We wanted to get some tips and strategies from someone who can think like a lawyer because she happens to be one. And we did, on my most recent episode of the Off the Record podcast (link below).

Sarah Mendiola, Esq., LPN, CPC, CPCO is the senior vice president of denials management for CloudMed. She is an attorney admitted to the Maryland State Bar and a former attorney for Washington and West, LLC. Her background includes a 10-year stint as an LPN for Mercy Medical Center in Baltimore. Coupled with coding and compliance credentials, Sarah brings a unique clinical/coding/legal perspective to the subject.

One recent troubling trend from auditors is pre-pay DRG downcoding. Auditors are beginning to audit prior to paying anything on the claim. Instead of downgrading the DRG and paying the lower rate, they deny the entire claim and refuse to pay until the hospital adjusts the claim based on the auditor’s suggested “correction.” “Not only is it not fair, fundamentally it doesn’t seem right,” says Mendiola—but it’s a reality.

What to do in this mine-field of an environment? Following are some battle-tested strategies Mendiola has found successful:

• Know the top 5 complications/comorbidities (CCs) and major CCs the payers are going after. Five that Mendiola sees across hospitals include 1) sepsis (in particular auditors using sepsis-3 criteria to deny sepsis-2 hospitals), 2) acute respiratory failure, 3) acute renal failure, 4) metabolic encephalopathy, and 5) severe protein calorie malnutrition. Implement a clinical policy to ensure that these conditions have a uniform, organization-wide definition and are coded accurately each and every time.

• Get to the point, with clarity. Be clear, concise, and write the appeal letter like somebody is going to read it at 4:30 p.m. on a Friday. “Get in everything that matters, but don’t be wordy,” she recommends.

• Include snippets directly from the medical record. This is especially impactful in the case of DRG downgrades. Pull in clinical indicators from the physician that support the ICD-10-CM or PCS code that is under review. “We don’t want the auditors to think too hard, but it right in their face where they can see it easily,” Mendiola says.

• Fight back, early and often. Don’t become a soft target. Rolling over invites more denials. Tell auditors in strong language when they’re using outdated clinical criteria to deny claims, i.e., serum proteins such as pre-albumin and albumin to deny severe protein calorie malnutrition (2) and go to the mat.

Like the above article? Listen to the full episode and click subscribe. Off the Record is free and new episodes appear every other week, in your podcast player of choice:

References

1. ACDIS, 2022 Industry Overview Survey.
2. Journal of the Academy of Nutrition and Dietetics, “Should Albumin and Prealbumin Be Used as Indicators for Malnutrition?”