Coding, Classification & Reimbursement

1.  Unsubstantiated Diagnosis

Posted 06-21-2017 13:29
​Curious as to what is being done with unsubstantiated diagnoses?   In the past, if a diagnosis was not supported by clinical criteria, we would send a query to the attending asking him his clinical indicators for the diagnosis. I realize the latest guideline states no clinical criteria needs to be used for the diagnosis to be stated.   However, due to DRG disputes we have resorted to the query to "have a leg to stand on" in case it is questioned.  For example, acute respiratory failure is stated without 2 parameters from the ABG, no physical signs, no increased rr etc.  Sometimes we will get an answer of "PC02 is ___ which makes this respiratory failure". We have been then coding  the failure thinking-- we asked and we can't ignore his clinical support although it differs from ours.  Sometimes when we include the established criteria they will retract the  dx and state "acute exacerbation of COPD without failure".
I had a case the other day where I asked for the clinical support  for pneumonia. I had no xray findings, no elevated wbcs, no fever, no sputum. After the query the response was "wheezing".   I would for sure lose this in a dispute.
How are you all dealing with these types of cases?  Thanks for any help you can offer

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Kimberly Tamburrino RHIA
HIM Inpatient Coder
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2.  RE: Unsubstantiated Diagnosis

Posted 06-22-2017 10:01
​Do you have a CDI department and/or physician advisor at your hospital?  If so, they should be the ones that are attempting to get clear documentation from the physician while the patient is still in the hospital.  We follow a similar process.  If the chart makes it to coding and the coder feels a diagnosis does not meet clinical indicators, the chart is reviewed by a CDI nurse.  If the CDI nurse feels that the documentation supports the diagnosis, then the coder codes as it is documented.  If the CDI nurse agrees that the clinical indicators are lacking, she will send the chart to the physician advisor for review.  If the physician advisors believes that the documentation supports the physician's diagnosis, then the coder will code the diagnosis without any further action.  If the physician advisor agrees that the clinical indicators have not been met, the CDI nurse sends a "clinical validation" query to the physician asking for any additional documentation to support the diagnosis.  The physician may then retract the diagnosis, or provide an explanation (usually in the format of x+y=z) and regardless of what coding/CDI think, the diagnosis is coded as documented by the physician.

Denials continue to be a problem with insurance companies imparting their own clinical indicators and blatantly ignoring the opinion of the physician.  We do our best to appeal.  Sometimes we are successful and sometimes not.

Greta

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Greta Ryan, RHIA, CCS, CCS-P
Coding & Compliance Analyst
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3.  RE: Unsubstantiated Diagnosis

Posted 06-22-2017 15:27
Greta,
​I am curious on your process and how long it takes to go through all the steps you have and keep the A/R down while the account is held. Or do you code the account bill it as is and correct claim the account after all your steps have been concluded.

As you say in your post and I agree;
Denials continue to be a problem with insurance companies ( and the RAC) imparting their own clinical indicators and blatantly ignoring the opinion of the physician.  We do our best to appeal.  Sometimes we are successful and sometimes not.
Greta Ryan,  06-22-2017 10:0
 


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Donna Walker-Thomas
Director of Coding
The Miriam Hospital
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4.  RE: Unsubstantiated Diagnosis

Posted 06-23-2017 10:29
​If the chart only requires additional CDI review, that usually occurs pretty quickly, can be the same day it is received from the coder.  Our physician advisor is fairly quick as well.  If it does have to go back to the attending physician, if there is no response to the query in 5 days, the query is sent again.  If no response after 7 days, the provider is notified via email requesting a 48 hr response.  If no response after 14 days, the chart is coded as documented.  Thankfully, we don't have too many of these on the coding side as we have a pretty good CDI team in place so I don't think that it has much affect on A/R.  Since we have gone to electronic queries, our response time is much better, also we have some physician groups (our hospitalists for example) who are incentivized to respond to their queries in a timely  manner.

Greta

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Greta Ryan, RHIA, CCS, CCS-P
Coding & Compliance Analyst
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5.  RE: Unsubstantiated Diagnosis

Posted 29 days ago
​Thank you Greta! I found your response helpful and like your idea. :)  We currently do not have a physician champion/advisor but we have two CDI specialists.  We all(coder and cdi) work on charts concurrently and try our best to get these types of issues resolved prior to discharge.  However, sometime they do not get answered before discharge or the chart is not reviewed as we not code 100% concurrently. Thank you so much for your perspective!

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Kimberly Tamburrino RHIA
HIM Inpatient Coder
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6.  RE: Unsubstantiated Diagnosis

Posted 28 days ago
Hi, Kimberly - We deal with these types of cases in a similar manner - the coder refers the case to the CDI nurse assigned to that unit.  The Nurse reviews and will either send a query to give the physician a chance to review the diagnosis and corroborate that yes, the patient has this condition, or not, and the coder then codes it.  We then have had a clinician make the clinical validation.  If there are disagreements between the coder and CDI, it is escalated to management and/or our Physician Advisors.
In my opinion, you are doing your due diligence.  The payers having their own clinical criteria to judge the cases on is a whole other issue!

Janice ​

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[Janice] [Noller, RHIA, CDIP, CCS]
[Inpatient Coding Educator][University of Utah Health Care][Salt Lake City][Utah]
[Janice.noller@hsc.utah.edu]
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