1 Denials and CDI: A Recovery Auditor s Perspective Tim Garrett, MD Medical Director Barb Brant, RN, CCDS, CDIP, CCS Sr. Clinical Trainer/DRG Auditors Cotiviti, Atlanta, GA 2 Polling Question #1 Does inpatient denial data drive CDI performance and documentation education efforts at your facility? No Yes N/A 3 1
4 Learning Objectives At the completion of this educational activity, the learner will be able to: Identify conditions at risk for audits. Analyze denial data to restructure CDI performance metrics. Illustrate the need for internal guidelines which clinically define diagnoses at risk for denial. Describe how to communicate denial outcome data to physician providers for improved documentation. Bridging CDI With Audit Processes Barb Brant, BSN, CCDS, CDIP, CCS 5 Role of CDI Professionals Key CDI performance indicators CMI focus: Optimal DRG assignment $ CDI program justification CDI expansions: Ambulatory, ER, quality, SOI, DRG validation 6 2
7 Clinical Validation Op mal CDI performance op mal reimbursement. Recovery Auditors review documentation for correct assignment: Correct coding Sequencing POS Performance of non covered services Medical necessity of services Clinical validation This discussion will focus on clinical validation audits. Medical necessity Non covered service Audit Types Clinical validation POS Coding Know Your Own Risk Areas Necessary to identify baseline performance: Diagnoses at risk (e.g., CC/MCC) Repetitive coding errors Integral conditions POA errors Unrelated OR DRGs Combination codes Ineffective or leading queries Conflicting diagnoses This will assist the CDI professional to: Ensure documentation supports the condition described Prevent down coding Ensure surgical procedures are supported 8 Audit Process Claim selection for audits is often based on complex algorithms from payer claim data The goal of clinical validation is to ensure accurate data was reported that accurately represents the patient s condition and services provided: For the provider as well as the payer to prevent fraudulent practices (intentional or unintentional) Can identify underpayments as well as overpayments Clinical validation is not an isolated auditing task: Requires a comprehensive record review Performed by clinicians (i.e., RNs with coding credentials and physician guidance and/or review) Clinical indicators and the patient s overall condition are reviewed to confirm diagnosis criteria were met 9 3
10 CDI Bridged With Denial Management Pros: Provides an avenue for shared data and CDI corroboration for needed improvement areas Identification of physician documentation educational needs Knowledge sharing between departments potential coding education for CDI staff, and clinical education for denial staff Improved ability to identify documentation gaps Identify diagnoses at risk without clinical definitions for validity Cons: Time lag on audit determinations Denials and CDI often not integrated departments Denial process and/or software not integrated with CDI tracking systems Often outsourced Costly and time consuming with repetitive layers of appeal processes Meaningful Denial Data for CDI Date of denial: Clinical consensus for diagnosis definitions can change over time (e.g., sepsis) Denial type: Identify trends and risks for diagnosis removal and downcoding to a less severe condition Volume of denial type: To develop priority plan for improvement Physician: Identify personal trends in documentation or overall problems Assist in developing educational plan 11 CDI and Use of Denial Data Action plan: Track problematic diagnoses: Perform a focused review Develop acceptable physician developed standard clinical parameters Identify physician education needs and perform education Query development: Potential for both coding and CDI queries Include clinical criteria supporting diagnosis and need for clarification Best to have diagnoses clarified before DC Evaluate and measure performance improvements: Perform follow up focus review 12 4
13 CDI Cycle in Clinical Validation Corroboration with denial team Data sharing Identify denials based on diagnoses Identify conditions at risk for denial Obtain physician input for facility wide clinical definitions CDI review of claim data to identify specific gaps in documentation Ongoing corroboration for continued improvement in denial rate Improved claim integrity and audit protection Develop measurable goals for improvement Provide real time physician education Share diagnosis clinical definitions Physician Documentation Performance Health systems are becoming proactive to assist efforts for improved physician documentation: Built into the bonus structure for employed physicians: Query response rate Response types (e.g., repeated unable to determine ) Built into the re credentialing process for non employed physicians: Maintain practice privileges 14 Obstacles for Clinical Validation Facility wide acceptance of clinical definitions: Evidence based medicine Often a subjective concept Corroboration between physicians, CDI, and coding professionals Physician buy in and participation in process: Specialist input imperative Healthcare provider is responsible for establishing diagnoses Dependence on repetitive queries for clarity 15 5
16 Obstacles for Clinical Validation Staff selection to perform clinical validation: Credentials, experience, and education Ongoing educational needs: Turnover rates of CDI staff and physicians Down querying need: Documentation does not support severity of condition Opportunity to engage physician champions to create clinical parameters to support diagnoses Queries and Clinical Validation Content of clinical information in query structure is reviewed: Heading of query template often contains diagnosis that is not documented within the record Response options lead to one diagnosis Lack of other or unable to determine options Clinical data does not support diagnosis choices Query date 17 Clinical Validation Tim Garrett, MD 18 6
19 Clinical Validation an Important Component 3 main components of DRG audit: Documentation verification Is a diagnosis or procedure actually documented? Coding validation (DRG validation) Were coding guidelines and Coding Clinic followed? Clinical validation Does the clinical data in the medical record support the diagnosis? What Is Clinical Validation? The Centers for Medicare and Medicaid Services (CMS) Recovery Audit Contractor (RAC) Scope of Work 2013 includes the following statement: Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or post payment claim determination. Clinical validation is performed by a clinician (RN, CMD or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials. In other words, clinical validation answers this question: Does the clinical data in the medical record support the diagnoses on the claim? 20 Clinical Validation Informational Basis The medical record including physician queries The medical literature Evidence based medicine Expert consultation 21 7
22 Clinical Validation Regulatory Basis The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient s progress Medicare Conditions of Participation, Content of the Record: 482.24 DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. CMS Program Integrity Manual (PIM); Publication 100 08, Chapter 6, Section 6.5.3; DRG Validation Review Clinical Validation Regulatory Basis The assignment of a diagnosis code [by the coder] is based on the provider s diagnostic statement that the condition exists. The provider s statement that the patient has a particular condition is sufficient. ICD 10 CM, Official Coding Guidelines (2017) I.A.19. The recently updated Coding Guidelines are nothing new and do not contradict CMS regulations they complement them. The bridge? CDI! 23 Clinical Validation Common Findings Taken as a whole, the majority of charts have adequate to excellent documentation When it is gray, we side with the provider 24 8
25 Clinical Validation Common Findings Some common problem areas: Entering an acute code when the clinical information points toward a chronic condition only Entering a diagnosis code that is only supported by a lab test Entering a diagnosis code for a condition that is inherent in another coded condition for example, mesenteric ischemia and a hernia with gangrene code Improper queries Clinical Validation Case Example An adult is admitted with nausea. No abdominal pain. A CT of the abdomen shows no acute abnormalities. The amylase is 100 (upper limit of normal = 85) and lipase is 200 (upper limit of normal = 160). The American College of Gastroenterology requires 2/3 of the following to validate acute pancreatitis: Acute abdominal pain consistent with pancreatitis Amylase and/or lipase elevation of 3 times the upper limit of normal Imaging findings consistent with acute pancreatitis This patient s clinical information does not support a diagnosis of acute pancreatitis. A physician query is warranted to clarify the diagnosis that should be entered as the principal diagnosis on the claim 26 Clinical Validation Case Example A woman is admitted for an ankle fracture. It is treated with open reduction/internal fixation. The patient reports an incidental symptom of dysuria, and the physician documents a UTI. A urinalysis shows 100 WBCs. The patient was already on antibiotics for a sinus infection at the time of admission. The subsequent urine culture is negative. The standard for diagnosing a urinary tract infection (UTI) is a positive urine culture. However, in this case, the clinical information points toward the presence of a UTI. The antibiotic likely interfered with the culture result. Thus, even though the urine culture is negative, the UTI code on the claim will be allowed. 27 9
28 Clinical Validation Case Example A non diabetic patient is admitted in June 2016 for right leg cellulitis. The patient s WBC count is 16,000 and oral temperature is 101⁰ F. Vital signs are otherwise normal. The patient is treated with IV antibiotics and discharged after 1 day. A diagnosis of sepsis is entered on the claim. The Sepsis 3 consensus paper was published in February 2016 and gives criteria for defining sepsis. Even as long ago as 2003, the Sepsis 2 paper established that SIRS criteria were insufficient to identify sepsis by themselves. The patient s signs and symptoms are consistent with cellulitis, not sepsis. Clinical Validation Case Example A patient is admitted with an exacerbation of COPD. There was an isolated oxygen saturation of 89% on room air near the time of admission. The patient s room air saturation was otherwise > 90%. There was no documentation of increased work of breathing (patient talking in complete sentences, no accessory muscle use). The patient was given oxygen 2 liters/minute per nasal cannula for 1 hour. At discharge, the oxygen saturation was 94% on room air. There is no documentation of respiratory failure by the physician; however, the code for acute respiratory failure is entered on the claim. The claim is denied. On appeal 90 days later, the hospital submits a physician query completed 2 days prior that reads: Did you intend to diagnose acute respiratory failure? Yes No There is no physician documentation of acute respiratory failure in the original medical record. The clinical information in the medical record does not support acute respiratory failure. The physician query is leading and late. This denial will be upheld. 29 Thank you. Questions? Tim.Garrett@cotiviti.com Barbara.Brant@cotivit.com 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 at the front of the program guide. 30 10