2022 CDI Week bonus Q&A: Denial trends and CDI involvement

CDI Strategies - Volume 16, Issue 40

As part of the twelfth annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of industry topics. Leyna Belcher, DNP-C, MSN, RN, CCDS, CCDS-O, CDI educator at West Virginia University (WVU) Medicine Enterprise System in Morgantown, West Virginia, answered these questions. She is a member of the 2022 ACDIS Furthering Education Committee. For questions about the committee or the Q&A, contact ACDIS Associate Editor Jess Fluegel (jfluegel@acdis.org).

Q: Nearly 68% of 2022 CDI Week Industry Survey respondents are currently involved in the denials management or appeals process, up nearly 10% from the last time this topic was covered in the CDI Week Industry Survey in 2020 (59%). Why do you think this percentage has jumped over the last two years? Do you think the COVID-19-related financial implications had an impact?

A: CDI efforts have become a trusted resource to multiple departments, including denials teams, for help identifying gaps or bridging gaps in documentation. Denials teams have realized the value of CDI work as a point of reference for supporting diagnoses within the medical record, even when the record isn’t black and white upon a first review. CDI specialists’ unique ability to make those connections is crucial. Because every health system was hit hard financially by COVID, recuperating and preserving revenue in every aspect of healthcare has become even more relevant to each system’s goals, including denials.

Q: How is your CDI team involved with denials? Is it informally on a case-by-case basis, directly helping with appeal letters, or something else in between? Who on your team is involved with denials management and/or appeals?

A: Our CDI team consults on cases that were denied for clinical support of specific diagnoses or DRG downgrades. Usually, we will be sent a case from the denials department and one of our CDI educators and/or CDI level 3 denial project leads will review the specific denial letter for the reasons the claim is being denied, then offer a CDI perspective on how much support of that diagnosis is in the medical record. Once the CDI professional has completed their review, a recommendation is sent to the denials team on whether the CDI professional believes there is enough to support an appeal.

Q: According to respondents, 30.22% said the majority of their denials originate from private payers. Does it surprise you that private payers seem to be surpassing Medicare as the biggest group denying claims? Why or why not? Does this mirror your experience?

A: Denials from private payers are the majority of denied claims we see. It is not a surprise that private payers are the majority, since they have less oversight as to how they regulate denying claims and why. Denials from the private payers seem to be more frequent and targeted to specific diagnoses or cases with a single CC/MCC. Private payers often have their own criteria, or they jump from using one set of criteria to another to fit their needs of denying a case at that time. There seems to be no consistency in what criteria they attempt to hold hospital organizations to for support of a diagnosis. What is accepted for one case will be denied on the next case with the same support.

Q: Nearly 70% of respondents reported that sepsis is one of their top denied diagnoses, followed by 52.52% who said respiratory failure was in their top list. Why do you think these two diagnoses pose such a denial risk? What types of diagnoses do you see most frequently denied? How have you worked to fight against those denials?

A: I am not surprised these are the top denial diagnoses, since they are left open to interpretation by the provider themselves at the time the patient has the signs and symptoms. Sepsis is even more tricky to support as a diagnosis depending on the definition of sepsis and diagnostic criteria set the hospital and payers use. I have seen private payers steer away from Sepsis-2 and more often use Sepsis-3 criteria. However, Sepsis-3 criteria are more difficult to use to offer a solid interpretation of a “dysregulated host response,” even with SOFA criteria support.

Respiratory failure is also difficult because there is not a cutoff definition of what qualifies as respiratory failure and what does not. P/F ratio is a great indicator, but not many providers (or payers) use P/F ratios to validate respiratory failure. Respiratory failure patients do not always have to be on six liters per minute of oxygen via nasal cannula for four days, but some payers expect to see those indicators and more for any diagnosis of respiratory failure. With these diagnoses that are left to the prerogative of the providers to document based on their clinical judgment, but also the prerogative of the payers to deny, we are left with rogue definitions and interpretations. Many of our denials are sepsis and respiratory failure, as well as other diagnoses in a similar category, like encephalopathy and malnutrition.

Q: What other departments or groups does your CDI department collaborate with on the denials management/appeals process? In what capacity do they collaborate (e.g., through monthly meetings, during the appeal writing process, etc.)?

A: We collaborate with our coding department to ensure we are meeting all the requirements of the coding guidelines. WVU Medicine’s CDI program also collaborates with our physician advising team for medical necessity denials and additional support, if needed, to help review particularly difficult cases. Each denial is different, so we will reach out to any department that can help us validate a diagnosis, like a registered dietitian, to substantiate and appeal a claim.  

Q: The most common denial mitigation tactic is clinically validating high-risk diagnoses concurrently (cited by 46.88%), followed by reviewing denials on a case-by-case basis upon request (39.24%). What methods do you think are most effective and the best use of CDI time? If a CDI team doesn’t have access to denial volumes, how can they effectively choose a focus area?

A: Both avenues mitigate denials effectively, and really a combination of both will help sustain appeals and prevent denials. Education for the CDI team in how to validate a diagnosis, send clinical validity queries, and give provider education using denial examples is pertinent to prevent future denials preemptively. However, reviewing denials on a case-by-case basis ensures we are noticing trends in denial opportunity of our payers, knowing what education is needed, and creating more robust appeal letters. If a CDI team does not have access to denial volumes, using data from other organizations for education on those denial target diagnoses is essential. Targeting single CC/MCC DRG cases for review to protect against denials and Recovery Audit Contractors (RAC), and to determine when there is an additional CC/MCC opportunity, would also be beneficial.

Q: How do you measure the success of a CDI program’s involvement with this process? What metrics do you track, and how are you tracking them?

A: For CDI purposes, we track any cases sent to us on a spreadsheet and manually add the result of our findings. If we offer additional support for a recommendation of an appeal, we track whether the case was appealed and if that appeal was overturned. If the appeal was overturned and revenue preservation occurred, we track the amount of the preservation. If we did not recommend an appeal, we simply note that on the spreadsheet. We track if a CDI professional reviewed the case concurrently and what type of denial it was as well, to analyze trends and provide education based on the denials to our providers and CDI team. We find tracking these is extremely beneficial not only to show the value of CDI efforts in the denials realm, but also to better learn the payers' habits and note educational opportunities for the CDI team and providers.

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