Monday, October 19, 2020

Common Inpatient DRG Validation Coding Denials in 2020

by Theresa Andrews, RHIT

In Denials Management, it can be very useful to keep track of trends, including which denials you see the most often, and which are the most difficult to get overturned. Here are 2 of the most common coding denials that I have seen at our facility in 2020 (fellow Denials Coordinators, these may look familiar):

Use of J44.0 (COPD w/ lower respiratory infection) as principal diagnosis, with pneumonia as secondary diagnosis.

As I’m sure you all remember very well, the instructional note regarding the sequencing of these diagnoses has changed a few times in the recent past. At this point in time, code J44.0 has an instructional note to “Code also to identify the infection.” This “code also” note can be interpreted to mean that either code J44.0 or the code for the infection may be used as principal diagnosis depending on the circumstances of admission; however, auditors have really been targeting the use of J44.0 as PDX. We have received multiple audits where our facility had used code J44.0 as PDX, with the code for pneumonia as a secondary diagnosis. These audits always seem to state that the pneumonia should have been PDX because IV antibiotics were given for pneumonia, while no IV steroids were given for the COPD. There was one instance where IV steroids actually were given in the ER, but the audit still argued that the pneumonia was the main focus of treatment and therefore should have been PDX. We did attempt to appeal some of these denials, but they have proven very difficult to get overturned. Coder education was done at our facility explaining that coders should really be taking the specific treatment into account before choosing which diagnosis to assign as PDX in these cases. Regardless, this has definitely been a source of confusion for coders due to the recent changes in the instructional note, and auditors have definitely taken notice.

One additional point, make sure when you are reviewing denials that you are using the information that was in effect during the timeframe of the claim.  As noted above, guidance can change and your basis for overturning a denial for a current claim may well be different than what was applicable for claims from two or three years ago.

PCS Code for Excisional Debridement

Denials for excisional debridement have also proven to be very difficult to get overturned, although this can be done. As a refresher, Coding Clinic states that in order for a debridement to be considered excisional, the provider must blatantly state that the debridement was excisional, and/or the procedure must meet the root operation of excision, which is “cutting out or off, without replacement, a portion of a body part.” At least at our facility, it is very rare for a physician to specifically state that he or she is performing an “excisional debridement,” and so, more often than not, coders are looking for documentation to support that the physician truly excised a portion of a body part (usually subcutaneous tissue). We have gotten some of these denials overturned, but we have also sent out coder education regarding this topic so that the coders are able to recognize when a query is necessary regarding which type of debridement has actually been performed.

These are just a few of the more common coding denials I have seen lately. Your experience may be similar but regardless, it is up to the denial management team in collaboration with coding professionals and CDI specialists to challenge denials when appropriate and educate appropriate staff when a legitimate issue is identified to prevent future recurrences.

About the Author

Theresa Andrews, RHIT is currently working as the Revenue Integrity Analyst at Weirton Medical Center. Theresa graduated from the HIM Associate's Degree program at Eastern Gateway Community College in 2016. Since then, she has worked at WMC as a Scan Technician, Coder, Coding Team Lead, Denials Coordinator, and now the Revenue Integrity Analyst. .