Defending Pediatric Denials in an Adult Denial World · Title: Microsoft PowerPoint -...

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This is the Full Title of a Session

Defending Pediatric Denials in an Adult Denial World

Nicole Cuellar, RN, BSN, CCDS Clinical Documentation SpecialistSeattle Children’s HospitalSeattle, WA

2019 Copyright, HCPro, a division of Simplify Compliance LLC, and/or session presenter(s). All rights reserved. These materials may not be copied without written permission.

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:– Describe a typical institutional process for claim denials– Review and explain rebuttal techniques for all types of denials– Gain an understanding of the differences in adult vs. pediatric clinical criteria for several commonly denied diagnoses

– Utilize CDI workflow to decrease risk of common denials


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Seattle Children’s Hospital• We currently have 407 licensed beds (and climbing)

• In 2018, we had 12,144 admissions totaling 100,381 patient days

• We performed 16,084 total surgical procedures

• There were 50,644 emergency department visits and 280,743outpatient clinic visits

• 96% of our patients come from the WAMI region (Washington, Alaska, Montana and Idaho)


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Seattle Children’s CDI Program

• We report to revenue integrity and coding• We are a small team consisting of one RN for the inpatient departments and one RN for the outpatient clinics

• We are almost entirely remote but provide physician training at least monthly on campus


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Insurance Denials and Rebuttals


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How Does It Work at Seattle Children’s?

Revenue cycle receives denial letter

Letter transferred to inpatient coding manager

If issue is code assignment exclusively, handled by coding team

If issue is clinical validation/diagnosis‐specific denial, forwarded to CDI

CDI RN reviews chart to determine if rebuttal should be attempted

CDI RN crafts rebuttal response and sends back to coding and revenue cycle


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• Upon receipt of forwarded denials, the inpatient coding manager enters the denial information into a spreadsheet and alerts the coding and clinical documentation reviewers that new denials have been added as well as the targeted appeal date– Seattle Children’s does not use any formal denial software or data collection procedures

– All denial data and dates related to the appeal process are updated to this custom spreadsheet

– The inpatient coding manager ultimately owns the maintenance of this spreadsheet and oversight of the denial and appeal process


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• If provider input is needed, CDI reaches out to a department chief – Appeals are not routinely signed by a physician; however, we may seek an MD signature on a case‐by‐case basis, especially for high‐level appeals• Appeals are typically signed by CDI and the inpatient coding manager

– Seattle Children’s has engaged the medical director to participate in peer‐to‐peer conversations on occasion


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Standard Rebuttal Techniques


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Rebuttal Techniques

• Ensure adequate documentation was sent with the claim• Utilize coding logic, Coding Clinic, and chapter‐specific guidelines to defend principal diagnosis selection

• Create institution‐specific criteria to define diagnoses and clinical scenarios

• Leverage medical experts and research to clinically validate denied conditions


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Quick “Raise Your Hand” Question

• Are your queries part of the permanent medical record?– Yes– No– Unsure


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Rebuttal Techniques – Documentation

• At Seattle Children’s, our queries are electronic and permanent parts of our medical record

• Is HIM sending those query documents along with the progress notes, consults, and imaging results?


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• Work with HIM/medical records to ensure that all necessary pieces of documentation are sent with the claim to avoid denials due to lack of documentation evidence of a coded condition


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SCH response: Query documentation provided


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Auditor response: Findings overturned


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Rebuttal Techniques – Coding

• Defend principal diagnosis selection and secondary diagnosis codes with coding guidelines and Coding Clinic support


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Principal Diagnosis• The condition established after study to

be chiefly responsible for occasioning the admission– Consider if two or more diagnoses equally

meet the definition of principal diagnosis

Secondary Diagnosis• Additional conditions that affect patient

care in terms of requiring:– Clinical evaluation– Therapeutic treatment– Diagnostic procedures– Extended length of hospital stay– Increased nursing care and/or monitoring


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SCH response: Provided definition of, and evidence supporting, secondary diagnosis coding. Currently awaiting appeal response.


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Rebuttal Techniques – Institution‐Specific Definitions

• With provider partnership, establish facility‐specific definitions and criteria to defend code choices– These established coding guidelines can be used for denial defense purposes, but they also can decrease query volume when a standard outside of coding logic, but more in line with clinical presentation, can be developed• To decrease queries sent for remission status of leukemia, CDI collaborated with oncology to utilize the verbiage “MRD‐negative” and “on maintenance chemo” to imply leukemia in remission


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• Appropriate internal guidelines should not:– Conflict with the ICD‐10‐CM Official Guidelines for Coding and Reporting– Interpret abnormal results– Replace provider documentation


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Respiratory Failure

With collaboration between emergency medicine, critical care, pulmonology, and hospital medicine, Seattle Children’s adopted the following simple definition for respiratory failure in our facility:

SaO2 less than 88%, Pcap CO2 greater than 50, or both.


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SCH response: Provided respiratory failure definition


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Rebuttal Techniques – Clinical Validation

• Seek out clinical references and provider input to defend and validate denied diagnoses

• Determine facility criteria to ensure providers are utilizing standard diagnostic criteria for commonly deniable conditions


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• Sepsis: Seattle Children’s defines sepsis as a systemic inflammatory response (SIRS) in the setting of infection based on physician advisor recommendation and an UpToDate article regarding pediatric sepsis– SIRS

• The presence of 2 or more of the following criteria: elevated or decreased temp, tachycardia, tachypnea, elevated or decreased WBC count

– Severe sepsis• SIRS criteria in the setting of infection with acute organ dysfunction: ARDS, respiratory failure, cardiac failure, encephalopathy, liver failure, AKI

– Septic shock• SIRS criteria in the setting of infection with hemodynamic instability typically requiring vasopressor support

https://www.uptodate.com/contents/systemic‐inflammatory‐response‐syndrome‐sirs‐and‐sepsis‐in‐children‐definitions‐epidemiology‐clinical‐manifestations‐and‐diagnosis?search=pediatric%20sepsis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1


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• Malnutrition: Seattle Children’s utilizes ASPEN criteria when defending malnutrition denials


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SCH response: Provided clinical validation utilizing SCH‐approved resources.


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Pediatric Considerations


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Malnutrition• Denials may utilize albumin and BMI criteria to invalidate a malnutrition diagnosis:

https://www.sciencedirect.com/science/article/pii/S0002822395001239#FIG1

IMAGE


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• Seattle Children’s Hospital nutritionists diagnose malnutrition using ASPEN criteria. A query is often sent to get this diagnosis restated by a provider.

Malnutrition


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Acute Kidney Injury/Acute Renal FailureDenials typically utilize RIFLE criteria to invalidate an AKI diagnosis:

https://ccforum.biomedcentral.com/articles/10.1186/cc2872

IMAGE


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Acute Kidney Injury/Acute Renal FailureSeattle Children’s uses KDIGO guidelines to diagnose AKI:

https://kdigo.org/wp‐content/uploads/2016/10/KDIGO‐2012‐AKI‐Guideline‐English.pdf

IMAGE


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Acute Kidney Injury/Acute Renal Failure


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SCH response: Provided pediatric criteria. Currently awaiting appeal response.


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Denial Prevention and Rebuttal Success


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• If current documentation will code to a complication, query the provider to confirm or rule out:– “Postoperative” conditions (respiratory failure, heart failure, ileus)– CLABSI– Surgical “complications”

• Create organization‐specific clinical definitions or coding guidelines– Include medical faculty in drafting guideline documents


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• If documentation is vague, utilizes uncertain terminology (“possible concern for,” etc.), or is contradicted within the medical record, query the provider to establish if the diagnosis is ruled in or out– Is a diagnosis noted in the ED and then not again during the admission?– Did a specialty consult describe a condition in a differing fashion than the attending service line?

– Are diagnoses documented with inconsistent degrees of severity? (AKI vs. renal insufficiency, respiratory distress vs. respiratory failure)


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• Follow trends in denial data – If incorrect coding is frequently implicated, leverage coding educator to provide feedback and education to coders

– If trends are related to clinical documentation issues, leverage CDI RN to provide feedback and education to clinical service lines• Seattle Children’s noted a trend in respiratory failure denials and created our internal definition of this condition in response


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• Too late to prevent? Increase your chances of a successful rebuttal:

– Take notice of the credentials of the person signing the denial letter. Denial signed by an MD? Have a physician advisor or medical director sign the rebuttal letter.

– Engage payer relations as necessary to prevent denials that fall outside of the contractual agreements


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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section of the program guide.


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