national physician advisor conference of acute organ dysfunction occasionally, the third-party...

BRIDGING THE GAP BETWEEN CONFUSION AND CLARITY IN HEALTHCARE

National Physician Advisor ConferenceNPAC2019

Clinical Validation Denials: How to Fight and Prevent Them

Denise Wilson, MS, RN, RRTVP Appeal ServicesDenial Research Group + AppealMastersTowson, MD

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• Definition of clinical validation (CV)

• Top CV diagnoses being targeted by auditors/payers and the why behind it

• How a lack of consistency between physicians and coders in the terms used and lack of standardization of disease criteria contributes to CV denials

• How to attack disparities among auditor/payer and provider diagnostic criteria/clinical indicators

• Defensive documentation – the importance of consistent, clear, comprehensive documentation to prevent denials

• Identifying the Root Cause of the denial when the payer is correct (gasp!) for learning opportunities

Learning Objectives

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Defining Clinical Validation

The definition of clinical validation (CV) and the top CV diagnoses being targeted by auditors/payers and the why behind it

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DRG Validation versus Clinical Validation (CV)

Per CMS, a DRG Validation Review:

✓Ensures that diagnostic and procedural information…as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the beneficiary's medical record.

Medicare Program Integrity Manual Chapter 6.5.3 - DRG Validation Review (Rev. 608, Issued: 08-14-15, Effective: 01-01-12, Implementation: 09-14-15)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c06.pdf


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Clinical Validation (CV)

✓Directs reviewers to question the clinical validity of diagnoses

✓“Clinical validation,” becomes part of Recovery Auditor Statement of Work, Sept 2011

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/downloads/090111racfinsow.pdf [p. 23]


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DRG Validation = determining correct codes and sequencing

This type of review shall be performed by a certified coder

Clinical validation = determining whether or not the patient truly possesses the conditions that were documented

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 a clinician with approved coding credentials – per the RAC SOW


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Suspension of Inpatient Hospital Reviews by CMSEasy TargetMajor Complications and Comorbidities (MCC) = High DollarsDiagnoses with varying interpretations of disease criteria ✓AKI, acute respiratory failure, sepsis, encephalopathy,

malnutrition✓Lack of standardization of disease criteria

Why Clinical Validation Audits

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✓Pneumonia

✓Sepsis

✓Malnutrition

✓Acute MI

✓Acute Heart Failure

✓Acute Respiratory Failure

✓Encephalopathy

✓Severe Malnutrition

✓Acute Pancreatitis

✓Acute Kidney Injury/Acute Renal Failure

✓Acute Blood Loss Anemia

✓Shock

Why Clinical Validation Audits

Diagnoses frequently targeted for clinical validation include:

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Certain diagnosis on a claim may be removed when one or more of the following circumstances occurs:

✓ Applicable laboratory, radiological or other supporting criteria (clinical indicators) are not located in the medical record

✓ The criteria for establishing a diagnosis is not evident in the record or is questionable

✓ There appears to be inconsistent medical record documentation

Risk Factors for CV Denials

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Bridging the Coder/Physician Terminology Gap

How a lack of consistency between physicians and coders in the terms used and lack of standardization of disease criteria contributes to CV denials

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The Four C's of Clinical Validation Documentation

Clear (Connect the Dots)

Consistent (Typical Chest Pain or Unstable Angina?)

Credible (Does the plan match the diagnosis?)

Coder Friendly (Renal Insufficiency, Acute Kidney Injury, ATN, Renal Failure)


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What makes coders crazy

✓Urosepsis – codes to nothing

✓Intubated for GCS of 7 – respiratory failure or something else?

✓Pulmonary insufficiency and respiratory insufficiency do not code to the same in code ICD-10

✓Insufficiency versus failure – clinical and coding differences

✓Sepsis syndrome – huh?


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• Leverage as experts in sequencing and Coding Clinic Rules

• Train in “Clinical light”

• Empower to “stop and ask”

• Proactive, holistic reviews

• Champion the coordination of CDI, CM

• Provide the physician voice

• Train in “CM light”

• Active part of clinical team (not in the basement)

• Train in “CDI light”

• Empower to refer cases to CDS and PA

Case Managers

CDS

CodersPhysician Advisors

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Bridging the Payer/Provider Diagnostic Chasm

How to attack disparities among auditor/payer and provider diagnostic criteria/clinical indicators

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Disconnect between clinical criteria used by the payer and clinical criteria used by the physician to diagnose

Bottom line -

Payers cling to one set of diagnostic criteria and never waver

To fight denials -

Critically and intelligently challenge that methodology


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CV Denial Letter Pneumonia:

Fever or hypothermia, cough with or without purulent sputum, dyspnea, chest discomfort, sweats, or rigors.

Respiratory assessment should reveal bronchial breath sounds, rales, or inspiratory crackles.

Parenchymal infiltrates or consolidation on chest radiograph are present with pneumonia.

Lab findings typically show leukocytosis.

(Current Medical Diagnosis & Treatment, McPhee and Papadakis, 2015)


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Twenty-one percent (22/105) of patients with a clinical diagnosis of CAP had negative chest radiographs at presentation. Fifty-five percent of patients with initially negative chest radiographs who had follow-up studies developed an infiltrate within 48 hours.

Hagaman JT, Rouan GW, Shipley RT, Panos RJ. Admission chest radiograph lacks sensitivity in the diagnosis of community-acquired pneumonia. Am J Med Sci. 2009 Apr. 337(4):236-40.


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CV Denial Letter Malnutrition:

According to the World Health Organization, criteria for severe malnutrition is defined by a BMI < 16, a 25% weight loss, characteristic physical signs, and prealbumin < 5 mg/dl.

There was no report of weight loss and no prealbumin was drawn.


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“Malnutrition is defined as a nutritional imbalance that can occur as a result of over-nutrition, under-nutrition, and underlying disease states impairing the absorption of nutrients.”

Barker L., Gout B., & Crowe T. (2011) Hospital Malnutrition: Prevalence, Identification and Impact on Patients and the Healthcare System. Int. J. Environ. Res. Public Health 8(2): 514-527.


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ASPEN Criteria = Severe Adult Malnutrition in the context of an acute illness or injury (2 or more of the following):

✓Insufficient energy intake (< 50% of estimated energy requirement for > 5 days)

✓Weight loss – with consideration given to the presence of over- or under-hydration (>2% over 1 week OR >5% over 1 mo. OR >7.5% over 3 mo.)

✓Moderate loss of muscle mass (aka: cachexia)

✓Moderate loss of subcutaneous fat (aka: cachexia)

✓Moderate to severe fluid accumulation, potentially masking weight loss (generalized or localized edema)

✓Diminished functional status as evidenced by hand grip


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SIRS + Infection or Sepsis-3?

October 2018

UHC announces plan to adopt Sepsis-3 criteria in their reviews starting 1/1/2019

January 2019

Greater New York Health Association and the New York State Department of Health (DOH) confirmed UHC would not implement Sepsis-3 criteria in the state of New York.

https://www.uhcprovider.com/content/dam/provider/docs/public/resources/news/2018/network-bulletin/October-Interactive-Network-Bulletin-2018.pdf


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State Policy Approaches to Sepsis Prevention and Early Recognition

• IL - Gabby's Law – Illinois Senate Bill 2403 (SB2403)

• NY - Rory’s Regulations – NYCRR Title 10 Sections 405.2, 405.4, and 405.7

• OH - Reducing Sepsis Mortality in Ohio – Ohio Hospital Association’s Sepsis Initiative

• WI - “Think Katie First” – Wisconsin Hospital Association’s Partners for Patients Initiative

https://www.cdc.gov/hai/state-resources/policy.html


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Many payer denials are issued by a third-party contractors

Most are using, but not specifically quoting or citing, Sepsis-3 criteria

The denial language almost always includes some phrasing about the lack of evidence of acute organ dysfunction

Occasionally, the third-party contractors will mention SOFA scores, but without any specific citing of the SOFA criteria

Wide variation in the consistency, quality, and specificity of denial rationales


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There is not consensus in the medical community as to what constitutes “Sepsis”. Physicians are not bound by one group’s opinions as to what constitutes a certain diagnosis.

The Third International Consensus Definitions for Sepsis and Septic Shock guidelines very clearly state, "Neither qSOFA nor SOFA is intended to be a stand-alone definition of sepsis."


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Defensive Documentation

The importance of consistent, clear, comprehensive documentation to prevent denials

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Supporting Medical Record Documentation

✓ Physician documentation evidencing the condition

✓ Clinical indicators supporting the condition

✓ Diagnostic test results confirming the condition

✓ Physician documentation that connects the dots between the clinical indicators, the diagnostic test results, and the diagnosis


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Physical Exam: left leg: +3 pitting edema up to thigh. + erythema, warmth. + tenderness + weeping. Erythema up to groin and lymphadenopathy.

Problem: Sepsis 2/2 left leg cellulitis

Plan:

✓ Will get CK

✓ Seen by vascular-appreciate recs

✓ Leg elevation. Pt responded to only linezolid in past-will continue

✓ Triamcinolone

✓ Will f/u blood cx


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Progress Note:1. Recurrent LLE cellulitis – Pt has had in past and reportedly only responded to Zyvox. Will start Zyvox and also Zosyn as pt. presented meeting criteria for severe sepsis. Vascular consulted and recommended IV abx. Inflammatory markers extremely elevated raises suspicion of possible osteo. Would consider MRI to evaluate.2. Severe sepsis – Met SIRS based on WBCs and HR. AKI and transaminase indicated end-organ damage, meeting severe sepsis criteria with likely source LLE cellulitis.


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Overturn Decision Letter from Independent Review Entity:

There was consistent physician documentation in the medical record establishing the clinical evidence by which sepsis was diagnosed and treated. The severity of the conditions required continuous treatment, evaluation, monitoring with abnormal clinical values attributed to sepsis by the physicians caring for the patient. Documentation throughout the record established the presence of sepsis and dysregulated systemic, renal and hepatic response to the condition.


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• Be consistent in documentation of the diagnosis – beginning, middle, end

• Explain how the clinical evidence supports the diagnosis

• Explain why clinical test results confirm the diagnosis

• Show how the plan of care is addressing the diagnosis


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Root Cause When the Payer is Right

Identifying the Root Cause of the denial when the payer is correct (gasp!) for learning opportunities

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69-year-old female with past medical history of dementia brought to the ED today by her husband for evaluation of progressive poor appetite and failure to thrive

✓ Temperature 101.4

✓ Pulse 108

✓ Respiratory rate 20

✓ WBCs 5.8

✓ Influenza A positive

✓ CXR Clear


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Physician Documentation:

Active Problems:

Sepsis due to pneumonia

Additional Assessment and Plan:

… Encephalopathy


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CV Denial Letter Sepsis:

A localized infection of influenza A was identified. Upon investigation, the diagnosis of sepsis was not supported by the clinical evidence. Though the patient was noted to have a temperature of 101.4, this finding is to be expected in a patient with influenza. There was no evidence in the medical record of a systemic response to infection beyond that expected with influenza to support the diagnosis of sepsis.


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Unfavorable Appeal Decision Letter:

In this case, an elevated temperature of 101.4, a heart rate of 108 and respirations of 20 were noted at triage. Laboratory studies showed a white blood cell count of 5.8; a normal lactic acid level of 1.4; and a serum creatinine range of 0.88 to 0.73. The platelets ranged from 140 to 165. The total bilirubin was 0.7. Confusion and listlessness were noted in the presence of known advanced Alzheimer's disease. Nasal swabs were positive for influenza type A.


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What We Can Do

Work as a team to fight and prevent denials

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What we can do - work as a team

• Leverage as experts in sequencing and Coding Clinic Rules

• Train in “Clinical light”

• Empower to “stop and ask.”

• Proactive, holistic reviews

• Champion the coordination of CDI, CM

• Provide the physician voice

• Train in “CM light”

• Active part of clinical team (not in the basement)

• Train in “CDI light”

• Empower to refer cases to CDS and PA

Case Managers

CDS

CodersPhysician Advisors

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Ongoing audit of high risk diagnoses including physician advisor supported audits to:

✓ Identify patterns of risky documentation

✓ Provide feedback loop for continued improvement of physician documentation

✓ Identify system improvements to support the “whole picture.”


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Focus and Educate on the Four C's of Clinical Validation Documentation

Clear

Consistent

Credible

Coder Friendly


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Courtesy Fred Monger, Beardstown, Il 2014

www.acpadvisors.org

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[email protected]

Thank you!

Clinical Validation Denials: How to Fight and Prevent Them

national physician advisor conference of acute organ dysfunction occasionally, the third-party...

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