Eight Top Denial Focus Areas for Auditors

by James S. Kennedy, MD, CCS, CDIP

Over the years there’s been a tsunami of denials from payers, Recovery Audit Contractors (RAC), and Medicare quality improvement organizations. This is due to the auditors’ removal of ICD-10-CM codes based on provider documentation; auditors can perceive that a patient did not have clinical indicators supporting the presence of the condition.

The recent release of the 2016 Surviving Sepsis Campaign’s International Guidelines for Management of Sepsis and Septic Shock added jet fuel to these denials. This guideline supported a redefinition of sepsis (known as Sepsis-3) as a life-threatening organ dysfunction caused by a dysregulated host response to infection.

As such, auditors are now saying that if a code for R65.20 (severe sepsis) or R65.21 (septic shock) is not submitted, other codes for sepsis (such as those in categories A40-A41) are invalid since the physician did not document any acute organ dysfunction as linked to the patient’s sepsis.

While coding is based only on provider documentation, hospitals and payers are authorized to have their own criteria to ascertain the clinical validity of any submitted code. As such, if a payer has criteria that differ from those of the provider or the facility, the payer can deny ICD-10-CM/PCS codes it deems not to fit these criteria.

It seems that not much can stop a payer from denying a code just because they want to. Coding Clinic, First Quarter 2014, pp. 16–17 gives further power for payers to ignore official ICD-10-CM conventions, guidelines, and advice by stating, essentially that the facility should work the payer to inform the payer about the rules and try to work it out.

I see no solution to this dilemma other than to address clinical validity as follows:

• Traditional Medicare – Through legislation
• State Medicaid – Through legislation or the state’s insurance commissioner
• Private insurance companies – Through contracting
• All three – Rigorous negotiation and implementation of clinical definitions with medical, clinical documentation integrity, coding, and compliance (as allowed by Coding Clinic, Fourth Quarter 2016, pp. 147–149) as to self-audit prior to bill submission and rigorously defend their coding when challenged by RACs.

As such, we must have our own definitions supported by credible references as well as working directly with the payer’s medical directors. Facilities must negotiate these definitions in their contracts with payers to stem the onerous burden of defending our clinically valid coding.

Allow me to review some of my favorite oft denied diagnoses and their references.

Sepsis: I am personally a big fan of Sepsis-3, which means that there should be explicit documentation of some organ dysfunction (notice that it does not have to be organ failure) due to sepsis to qualify for severe sepsis.

On the other hand, if you want to use Sepsis-2 criteria, clinical measures should focus on Medicare’s definition of Systemic Inflammatory Response Syndrome (SIRS) due to infection listed in its SEP-1 core measure. Other references include:

• New Sepsis Criteria: A Change We Should Not Make. By Steven Q. Simpson, MD, FCCP, and published in the Chest Journal
• Characterizing Systemic Immune Dysfunction Syndrome to Fill in the Gaps of SEPSIS-2 and SEPSIS-3 Definitions, also published in the Chest Journal
• Coding Clinic, Fourth Quarter 2016, pp. 147–149 (as discussed above)

Coma: The ICD-10-CM Index to Diseases classifies the term “unconsciousness” with coma. Patients must be unarousable to stimuli, such as voice, pain, or inner need. Terms like “semi-coma” or “obtundation” are still coma clinically, however, the provider must document coma or unconsciousness to obtain a coma code. Glasgow coma scales can also support a coma diagnosis.

References include Adams and Victor’s Principles of Neurology, 10th edition and Plum and Posner’s Diagnosis of Stupor and Coma /Edition 4.

Encephalopathy: A diffuse brain disease or global brain dysfunction manifested as an altered mental status. ICD-10-CM has many options for documenting its underlying cause, such as due to medications (toxic encephalopathy), metabolic issues (acute hypoglycemia, uremia, or hyponatremia), anoxia, and the like.

If a patient’s altered mental status (major neurocognitive disorder [dementia], delirium, or psychosis) can be explained by a named brain disease (Parkinson’s disease, Alzheimer’s disease, the late effect of stroke), then the term “encephalopathy” is integral to these diseases unless it is explicitly documented that the altered mental status differs from that of the underlying brain condition.

In other words, the physician must state terms like “toxic encephalopathy” or “metabolic encephalopathy” and describe what the toxin, poison, or metabolic issue is. References include Adams and Victor’s Principles of Neurology, 10th edition, and National Institutes of Health.

Acute respiratory failure: An acute failure to ventilate or oxygenate. Clinical indicators supporting acute respiratory failure were developed by the Maryland Hospital Association and are available on its website. Pediatric indicators are available here. All of these references support the need for high flow oxygen or outside ventilator support (CPAP, BiPAP, or mechanical ventilation). (To read an ACDIS White Paper focused on pediatric respiratory failure specifically, click here.)

Acute kidney injury: Of all the criteria out there, I promote the 2012 KDIGO criteria. The Acute Kidney Injury Network’s 2007 requirement for rehydration to assess the presence of acute kidney injury is no longer valid, and the risk, injury, failure, loss of kidney function, and endstage kidney disease criteria is so 2005.

Acute tubular necrosis (ATN): An acute kidney injury due to an endogenous (tumor lysis syndrome, rhabdomyolysis, severe sepsis, hemolysis) or exogenous toxin (ethylene glycol, aminoglycoside, radiology contrast, certain chemotherapy), is known to cause ATN, or renal ischemia. This is more common in patients with hemorrhage shock or with hypotension in the setting of using nonsteroidal anti-inflammatory drugs or angiotensin converting enzyme inhibitors.

Other precipitating causes, such as renal obstruction, profound hypovolemia, and other renal diseases (acute interstitial nephritis) are excluded. Creatinine elevation typically lasts over three days. While urine studies (urine microscopy, fractional excretion of sodium test) are strongly recommended, they are not required to make a presumptive diagnosis, especially if documented at the time of discharge in reasonable circumstances. References include Brenner and Rector’s The Kidney, 2-Volume Set and National Kidney Foundation Primer on Kidney Diseases (Sixth Edition).

Malnutrition: I remain a big fan of the American Society for Parenteral and Enteral Nutrition’s adult or pediatric malnutrition criteria. However, as I mentioned in my discussion of the Office of Inspector General’s scrutiny on Vidant in March, there’s no definitive definition of malnutrition that’s universally agreed on. But the whole facility needs to be on the same page about which definition to use.

Functional quadriplegia: The only definition for this is the 2017 ICD-10-CM Official Guidelines for Coding and Reporting. Read it carefully; it does require that the term “functional quadriplegia” must be documented in the chart.

Summary
There are many more that we can discuss. A great medical librarian or physician advisor can help CDI professional identify articles to use and some payers will even help too. I believe that the best time to decide this is during contract negotiation. I suggest that you start down that path today.

Editor’s note: This article originally appeared in JustCoding. Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at jkennedy@cdimd.com. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.

Copyright Association of Clinical Documentation Improvement Specialists (ACDIS).  Article reprinted with permission.