Denied!

According to an Experian Health Data report, the rate of insurance denials is increasing, up to between 10 to 15 percent. Anecdotally, hospitals can confirm that increase. Clinical validation has added a twist to insurance denials.

The most frequent topics I see in clinical denials are acute (on chronic) congestive heart failure, sepsis, toxic/metabolic encephalopathy, hyponatremia, acute respiratory failure, and severe malnutrition. While the physician may document these diagnoses, the clinical information behind the documentation must support them.

Each diagnosis must be consistently documented. If not, then a post-discharge query may resolve any ambiguity.

For acute congestive heart failure, insurers are looking for a positive chest X-ray, leg edema, and treatment with IV diuretics. The history and physical (H&P) should show evidence of edema. The medication administration record should show the use of IV diuretics (e.g., Lasix, Bumex, etc.).

For sepsis, there is a quandary regarding the criteria used to determine the diagnosis – Sep-2 or Sep-3. In some cases, I have seen a facility continuing to utilize SIRS (systemic inflammatory response syndrome). Insurers want facilities to utilize their criteria to determine sepsis. A denial will typically include reference to the payer’s criteria. Each facility should utilize the payor’s criteria when appealing the denial. In general, there should be a local infection with evidence of a systemic infection.

Toxic/metabolic encephalopathy is a condition in which the patient suffers from a change in alertness or has abnormal cognition. An electroencephalogram (EEG) may support this diagnosis but is not mandatory. Consistent documentation of improvement in the patient’s mental status is important. There should also be documentation of the source of the toxic/metabolic encephalopathy, if possible. The warning would be that mental changes are involved in other situations, such as appropriate response to correct use of a medication/anesthesia.

Another target for denial is hyponatremia. The insurer will review the patient’s sodium levels. The level payers often quote as being significant is 130. Remember that the changes in the ICD-10-CM Official Coding Guidelines state that to report the additional diagnosis, it must be clinically significant.

Acute respiratory failure is another target for denials. These cases will be reviewed for respiratory rate higher than 24 and documentation of tachypnea. Other symptoms include work of breathing or dyspnea. The treatment should include supplemental oxygen at an elevated level, Bi-PAP, or the use of a mechanical ventilator. It should be noted that the use of a ventilator is not required.

According to Focus for Health, approximately 40 million Americans suffer from malnutrition. Severe malnutrition is a major complication/comorbid condition (MCC) and is a target for clinical validation. Documentation of cachexia, muscle wasting, and unintentional weight loss should be clear. There should be evidence of treatment for these cases, such as nutrition consultation, tube feeding, or protein shakes.

Another focus for inpatient hospital coders is cases with one comorbid condition/complication or one major comorbid condition/complication. These conditions affect the MS-DRG assignment, and payers will try to disprove them to reduce reimbursement.

It is important for coders and clinical documentation specialists to work as a team. A team works together to accomplish a common goal. This team must be proactive, when possible. It is best to delay the submission of a claim by awaiting a response to a clinical validation query rather than fight the payer denial.