by Theresa Andrews, RHIT
Most of the time, coding denials would not be thought of as being beneficial to a facility. It can seem that insurance companies are just trying to manipulate coding guidelines to their advantage to reduce the amount of reimbursement a facility should be receiving. However, there are times when the audits do catch what I would consider to be a legitimate coding error. Still not sounding beneficial? Well, the silver lining of this is that it provides a great opportunity for coder education. Rather than ignoring these legitimate denials and hoping they don’t happen again, our facility finds that the best practice is to face the issue head on and provide education to coders, CDI, and anyone else that may benefit from the learning opportunity presented by these denials.
At our facility, the denials team will send out a simple yet detailed educational e-mail after receiving a denial that we believe to be a true coding error, especially if we have received multiple audits regarding the same diagnosis or coding guideline. These e-mails usually express one or both of the following:
- Situations when a query could have been helpful to secure a denied diagnosis
- Coding Clinics/Coding Guidelines that coders/CDI may be unaware of, or need refreshed on
For example, we have received several denials referencing Section III.C of the ICD-10-CM Official Coding Guidelines regarding uncertain diagnoses, which states the following: “If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” code the condition as if it existed or was established.” Coders are already aware that a diagnosis can be coded in the inpatient setting if it is documented with uncertainty; however, it can sometimes be overlooked whether the uncertain diagnosis was still documented at the time of discharge, and if it was not, there’s a good chance it will be denied. When this happens, sending out a quick refresher e-mail on this coding guideline can be a helpful reminder that coders should be querying in cases where an uncertain diagnosis is documented but is not mentioned at all at the time of discharge, to see whether this condition is still being considered as a possible diagnosis, or has been ruled out. Including CDI is also beneficial, since they are in direct communication with the doctors during the patient’s admission, and can remind the physicians to either continuously state the diagnoses or rule them out if they are no longer being considered.
We have also received multiple denials regarding serosal tears during surgery. These denials have referenced the same 2007 Coding Clinic titled “Intraoperative serosal tears” which states, “When a tear is documented in the operative report, such as a small serosal tear of the stomach, the surgeon should be queried as to whether the small tear was an incidental occurrence inherent in the surgical procedure or whether the tear should be considered by the physician to be a complication of the procedure.” This is another example of a great education opportunity.
There could be a number of reasons that the coding staff need refreshed on this guidance. Among them are: there is a brand-new coder with little experience; an outpatient coder who transitioned to inpatient coding, infrequent documentation of these serosal tears, lack of training for coding staff on accessing Coding Clinic material, or insufficient coding education on Coding Clinic guidance. Regardless, with this Coding Clinic from 2007, a review is definitely in order. After sending out a quick e-mail stating that we had been receiving denials for this, with the above-referenced Coding Clinic attached, the coders now know to query the physician asking whether a small serosal tear during surgery was an incidental occurrence, or was a clinically significant complication of the procedure.
Continuing education is crucial in the coding world, and there is an opportunity for some of this education to come from the Denials Team. In my experience, this can help your facility to ensure more accurate coding in the future as well as proactively prevent these coding denials – and that is definitely an advantage!
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. .