Does Coding Clinic Allow Payers to Make Their Own Clinical Criteria?

I would like to focus on clinical criteria today. It has been brought to my attention that some payers are citing the American Hospital Association (AHA) Coding Clinic, pages 147-149 of the 2016 fourth-quarter edition, to justify using their own criteria as the basis for denials.

The Coding Clinic advice attempts to explain Guideline I.A.19, “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

It is ironic that this guideline is specifically intended to explain that the coder is not permitted to assume diagnoses according to any published criteria, and then payers want to use this advice to justify their being able to discount diagnoses according to their own criteria.

The provider “may use a particular clinical definition or set of clinical criteria to establish a diagnosis,” but Coding Clinic cautions that the code is purely based on the documentation. The guidance states that “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.”

I don’t think they mean the word “may” as in “we are granting them permission.” I think they mean the word “may” in the sense of “might.”

Let’s dispel this fallacy right here and now. I have yet to see a facility that strictly mandates a physician to use a particular clinical definition or set of criteria to make a diagnosis. The organization may convene an internal group to discuss a condition and what they would like to see in order to make a diagnosis, but there is always some disclaimer in the written policy that the provider must be permitted to use their clinical judgment. I recommend that they call their internally derived recommendations “internal clinical guidelines.” A guideline is a statement or declaration of policy that sets general standards for an agency or facility but does not have the force or effect of law.

If a provider is not following an internal clinical guideline for a considered reason, they should document the rationale for their deviation. If there is concern that the provider has acted way out of the boundaries of generally accepted medical care, then there should be a clinical quality review of the care. The provider’s medical colleagues are qualified to judge whether they believe care was appropriate after an investigation, in the context of a specific patient and that provider’s past actions.

If payers are using generally accepted consensus-based criteria to judge medical care, then it is reasonable to generate clinical validation denials if the provider has substantially deviated. For instance, a provider made a diagnosis of acute kidney injury (AKI) with a creatinine of 1.6, but the patient had a baseline of 1.4 with known chronic kidney disease (CKD), stage 3a. Generally accepted KDIGO (Kidney Disease Improving Global Outcomes) criteria for AKI are an increase of serum creatinine of greater than 0.3 mg/dL within 48 hours or more than 1.5 times the baseline within the prior seven days. Unless the practitioner has some compelling underlying reason for departing from the criteria that they hadn’t documented, it would be understandable to deny the assertion of AKI in this patient.

But a payer should not be able to demand that for the diagnosis of AKI; the creatinine elevation must be greater than 2.0 mg/dL within 24 hours, just on their whim, apparently. It is unreasonable for payers to create their own proprietary clinical criteria that have no discernible basis in science or medicine, and for insurers to be allowed to require facilities to adhere to those secret criteria.

The Coding Clinic segment recognizes that clinical guidelines may be crafted by institutions or payers, but affirms that coding experts do not have the authority to validate criteria; as they note, it is out of the scope of the coding system.

If you have contracted with a payer and there is a stipulation that they may use their own clinical criteria to determine clinical validity, you should either insist that you have access to their established criteria, or better yet, strike that from the contract.

Making diagnoses and documenting them is not for the sake of the payer. It is for the patient. The provider is trying to deliver optimal care and report it accurately. If a payer quotes this Coding Clinic advice, include in your appeal:

The Coding Clinic advice states, “Only the physician, or other qualified healthcare professional legally accountable for establishing the patient’s diagnosis, can ‘diagnose’ the patient.” Furthermore, although Coding Clinic is giving its recommendations, they are also acknowledging that it is not up to them to rule on whether a particular definition or set of criteria are valid to establish a diagnosis. They explicitly state that it is out of the realm of the coding professional.

My advice is for facilities to have ongoing discussions about changing and current clinical criteria to foster best clinical practice. Providers should be instructed to document their thought process well and in a codable format. Clinical validation queries should be composed to ward off clinical validation denials, as per the last sentence of I.A.19.: “If there is conflicting medical record documentation, query the provider.”

If a payer denies a claim due to legitimate clinical validation concerns, give the money back; it was a loan. If they are making up capricious criteria to unjustly deny proper diagnoses, don’t take that lying down.

If they quote this Coding Clinic advice as being support for their being allowed to make up their own criteria and hold you to them, fight it.

And make sure the folks who enter into contract negotiations don’t sanction it, either.

Programming note:

Listen to Dr. Remer today when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.