Guest Post: Reduce denials by being proactive with documentation improvement
While many facilities have developed robust denial management teams and have implemented comprehensive procedures for submitting appeals, one of the more powerful strategies in reducing denials can be summed up with this well-known expression: Nip it in the bud.
In other words, while focusing efforts on recouping payment for legitimate claims is a necessary task, being proactive and tweaking processes early during the documentation phase to ensure that claims are submitted in a compliant fashion in the first place is one of the most effective strategies in reducing denials.
“I think it’s really important for [clinical documentation improvement] specialists to know what kinds of denials their facility is getting,” said Sarah C. Mendiola, Esq., LPN, CPC, an associate attorney with the law firm of Fotheringill & Wade, LLC, and the denial defense company of Washington & West, LLC, in Baltimore, Maryland. “How else are you able to prevent them on the front end? Even if you’re not actively involved in the denial management process … if you have team meetings on a monthly or quarterly basis, that can help you to develop some strategies as to how you can prevent some of these high-dollar denials and denials that are becoming prevalent among Medicare and commercial insurers.”
2-midnight rule challenges
The 2-midnight rule requires a signed and dated inpatient order, and the signature has to be legible. Note that this order has to be written at or before the time of admission, not retrospectively. The regulation also says that the order has to be supported by the physician admission and progress notes in order for the hospital to be paid for the inpatient services under Part A, Mendiola said.
“So it’s not enough to say that this patient needs to be an inpatient; the progress notes and the physician documentation need to reflect why,” she said.
There also needs to be an expectation of hospitalization spanning two midnights. Anything written in the progress note and any physician documentation should support this expectation, even if it’s just outlining the plan of care, indicating why treatment is going to take two midnights rather than something that can be accomplished in 24 hours. And while this expectation must be clearly noted, certification is not a requirement, meaning the physician no longer needs to state the words “I certify” when documenting that the patient’s treatment will need two midnights.
Note that there are two exceptions to this 2-midnight rule:
- When you have an inpatient-only procedure and when there are “unforeseen circumstances.”
- If the two-midnight stay was interrupted, make sure that the physician clearly documents the exception; there cannot just be a note from the nurse saying, “Patient left [against medical advice]. Notified the doctor.”
The following is an example of achievable documentation or something that facilities can work toward in terms of getting physicians to document the necessary details:
This is an 84-year-old patient admitted for treatment of a COPD exacerbation. It is expected that she will need to be in the hospital for two midnights. She has multiple comorbid conditions, including diabetes, CHF, and coronary artery disease. She is at risk for rapid deterioration respiratory failure and cardiac ischemia and requires IV antibiotics, frequent nebulizer treatments, and frequent vital signs. She typically requires 2–3 days of IV steroids and increased oxygen requirements.
“This is basically saying, ‘This patient is well-known to our facility. Every time she comes here, it’s usually at least two days before we can get her back on her feet,’” Mendiola said. “This documentation contains the necessary elements of patient history, comorbidities, assessment of risk, and the expected treatment. And the clincher is in the last sentence.”
Editor’s Note: This article was originally published in Just Coding.