MedLearn Publishing
RACmonitor
ICD10monitor
Search
RACmonitor

One Claim with Multiple Denials Calls for Smart Defense

CERT claim review highlights need for strategic approach.

How do you handle your appeals when there is more than one issue being denied? For example, if the payer denies both the medical necessity of the level of care as well as the coding of a procedure, what strategies should you employ to challenge it?
When two issues are being denied, the appeal strategy first of all will depend on whether the denials were issued at the same time. If the denials were issued at the same time (that is, within the same decision letter), then both issues should be appealed in the same appeal letter. This typically requires the collaboration of both a clinician and a coder to develop one cohesive response that addresses both issues.
If the two issues were denied at different times (that is, two separate decision letters were issued with different dates), then each issue should be treated as a separate denial with a separate appeal, even if the appeal time frames overlap. The obvious logic behind this is that the time frames for appeal will be different for each denial, depending on the date the denial was issued. Thus, the appeal for each issue should be filed separately so that time frames can be more easily managed.
Just recently I was reviewing a decision letter from the Comprehensive Error Rate Testing (CERT) contractor on the issue of a TAVR – that is, a trans-catheter aortic valve replacement, which is currently on the CMS inpatient-only list.
Essentially, the CERT contractor was reviewing the claim for this nine-day hospital stay to ensure it met the criteria for medical necessity, as outlined in the National Coverage Determination for this procedure. The contractor reviewed the documentation to ascertain whether certain elements, such as the required preoperative evaluation by two cardio-thoracic surgeons, were present in the record. Unfortunately, in this case, the required evaluations were not present, and the CERT denied the medical necessity of the procedure, resulting in down-coding of the DRG.
What I found interesting, though, was that the CERT went to great lengths to explain that the inpatient hospital admission for this inpatient-only procedure was in fact reasonable and medically necessary. The reasoning the CERT provided was that this patient’s intraoperative and postoperative complications included a need for a blood transfusion, BiPAP, monitoring of thrombocytopenia, and treatment of increased blood pressures.
So let’s imagine for a moment that the CERT contractor reviewed the medical necessity of a procedure that was not on the inpatient-only list. And let’s imagine that in this case, the patient experienced complications that warranted an inpatient admission, following the two-midnight rule. And let’s further imagine that in its decision letter following its review, the contractor issued a statement on the medical necessity of the inpatient admission, deeming it to be reasonable and medically necessary.
I would strongly encourage a provider to flag a case such as this as having been reviewed and approved for the appropriate level of care, even if that was not the original purpose of the review. Should this case ever be requested by any other CMS auditor for level-of-care review, I would certainly argue that it is no longer eligible.
And finally, I would be certain to reiterate in my appeal of the medical necessity of the procedure that the CERT contractor had deemed the inpatient admission to be reasonable and medically necessary.
The CERT denial letter and your appeal letter will serve as proof that this case was already reviewed for level of care, should any other CMS auditor attempt to pull it for review.
Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Denise Wilson MS, RN, RRT

Denise Wilson is a Senior Vice President at AppealMasters and serves as President of the Association for Healthcare Denial and Appeal Management (AHDAM). She also provides ongoing education and expert knowledge to internal and external clients on commercial and Medicare denials and appeals via web-based seminars, onsite training, written materials and one-on-one consultations. She created and trained an appeal-writing team, which has grown to a staff of more than 70 nurses, physicians and coders.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering Principal Diagnosis: Coding Precision, Medical Necessity, and Quality Impact

Mastering Principal Diagnosis: Coding Precision, Medical Necessity, and Quality Impact

Accurately determining the principal diagnosis is critical for compliant billing, appropriate reimbursement, and valid quality reporting — yet it remains one of the most subjective and error-prone areas in inpatient coding. In this expert-led session, Cheryl Ericson, RN, MS, CCDS, CDIP, demystifies the complexities of principal diagnosis assignment, bridging the gap between coding rules and clinical reality. Learn how to strengthen your organization’s coding accuracy, reduce denials, and ensure your documentation supports true medical necessity.

December 3, 2025

Proactive Denial Management: Data-Driven Strategies to Prevent Revenue Loss

Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.

November 25, 2025
Sepsis: Bridging the Clinical Documentation and Coding Gap to Reduce Denials

Sepsis: Bridging the Clinical Documentation and Coding Gap to Reduce Denials

Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.

September 24, 2025

Trending News

Featured Webcasts

Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue

Stay ahead of the 2026-2027 audit surge with “Top 10 Audit Targets for 2026-2027 for Hospitals & Physicians: Protect Your Revenue,” a high-impact webcast led by Michael Calahan, PA, MBA. This concise session gives hospitals and physicians clear insight into the most likely federal audit targets, such as E/M services, split/shared and critical care, observation and admissions, device credits, and Two-Midnight Rule changes, and shows how to tighten documentation, coding, and internal processes to reduce denials, recoupments, and penalties. Attendees walk away with practical best practices to protect revenue, strengthen compliance, and better prepare their teams for inevitable audits.

January 29, 2026

AI in Claims Auditing: Turning Compliance Risks into Defensible Systems

As AI reshapes healthcare compliance, the risk of biased outputs and opaque decision-making grows. This webcast, led by Frank Cohen, delivers a practical Four-Pillar Governance Framework—Transparency, Accountability, Fairness, and Explainability—to help you govern AI-driven claim auditing with confidence. Learn how to identify and mitigate bias, implement robust human oversight, and document defensible AI review processes that regulators and auditors will accept. Discover concrete remedies, from rotation protocols to uncertainty scoring, and actionable steps to evaluate vendors before contracts are signed. In a regulatory landscape that moves faster than ever, gain the tools to stay compliant, defend your processes, and reduce liability while maintaining operational effectiveness.

January 13, 2026
Surviving Federal Audits for Inpatient Rehab Facility Services

Surviving Federal Audits for Inpatient Rehab Facility Services

Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.

November 13, 2025

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Thank you for choosing us as your trusted education this year! We’re celebrating you with a buy one, get one free webcast. Use code TY2025 at checkout

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 1 with code CYBER25

No tricks—just treats! It’s the annual MedLearn Spooky Sale across all three brands. Save 31% off everything for one day only on October 31st with code SPOOKY25

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24