It seems that Coding Clinic 4th Qt 2016 page 147-149 seems to give payers cover to insist that physicians follow their definition or criteria in making a diagnosis. This makes it more difficult to appeal denials coming from various payers.
In the 4th Qt Coding Clinic in the last line it 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.
This will make it more difficult to appeal. Are others having this problem with payers and what can we do?
Perhaps facilities can set up their own criteria that physicians are required to use,for each of the targeted RAC diagnoses. If anyone uses that approach, does it help with your appeals where the payer is using a different set of criteria, if you point to your facilities criteria?