Should hospitals include clinical definitions in payer contracts? Hear one legal opinion

By Brian Murphy

Establishing facilitywide diagnosis definitions is the gold standard for many organizations. If providers and the CDI/coding team agree on what constitutes postoperative respiratory failure for example, clinical disagreements should be greatly reduced, the need for queries lessened, and coding accuracy improved.

Unfortunately, payers also (appear) to have the same leeway to define conditions, per AHA Coding Clinic.

Coding Clinic Q4 2016, pp. 147-149, states, “a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”

The “or a payer” bit from the above Coding Clinic has caused no end to headaches, as described by my guest on Off the Record, Richelle Marting, in the clip below.

Should organizations take the next step and get definitions written into their payer contracts, in an attempt to get both sides—hospitals and payers—to meet at the table? We discuss that and more in the full program.

Marting is a healthcare reimbursement attorney for Marting Law, LLC, and joined me on a recent episode of the Off the Record podcast.