Guest Post: Tips for appealing MS-DRG denials

by Sam Antonios, MD, FACP, FHM, CPE, CCDS

Over the last 18–24 months, health- care organizations have seen a surge in MS-DRG denials, sometimes referred to as clinical validation denials.

When reviewers from Medicare Advantage health plans, Recovery Auditors, or other private or contracted health plans analyze a clinical case submitted for reimbursement, they may determine that a particular disease should be removed from the claim. They argue that the clinical documentation in the medical record does not support the diagnosis submitted. In the vast majority of these cases, the removed diagnosis is a CC or MCC, which causes the MS-DRG to shift to a lower payment.

MS-DRG audits are nothing new, but their frequency has significantly increased over the last two years. In some circumstances, the volumes have been over- whelming. There have also been reports of cases where denials have been egregious, unjustified, or made with disregard for the treating physician’s opinion.

Although there is no surefire way to win an appeal, here are some tips to increase the likelihood of overturning MS-DRG denials.

One: If you believe the case has merit, file an appeal, even if the variance in dollar amount is insignificant. It may be tempting to let go of denials that minimally affect the reimbursement, but when the treating provider’s documentation is available, complete, and accurate, and the coding is correct per official coding guidelines, organizations should appeal. This maintains consistency and makes the appeals about data integrity, rather than payment.

Two: Write clearly and summarize first. The appeal reader will likely not want to spend a lot of time figuring out the intent of the appeal. The first few lines need to describe the clinical case and need for appeal succinctly. Additional details can be included in later paragraphs.

Also, remember to reference review articles, clinical guidelines, or other findings to support your appeal.

Three: Learn how to navigate the electronic health record (EHR) to find relevant information. The history and physical and the discharge summary may not capture the entire clinical picture.

Learn where to locate, and how to decipher, emergency department documentation, consultant reports, progress notes, nursing notes, and other provider documentation, which can often include vital information to a support an appeal.

Additionally, respiratory notes can reveal the status of the patient, including lung exams, respiratory effort, and need for respiratory treatments. The goal should be to offer a complete and accurate clinical picture of the patient.

Four: If possible, review records from transferring facilities to help describe the patient’s case. These records are likely scanned into the record later in the patient care process, but they should be collected before an appeal. Creatinine levels, electrolytes, and other laboratory findings can help differentiate acute and chronic symptoms and conditions.

Five: Keep track of denials electronically. Preferably, use denial-tracking software. If such software is not available, or too costly for your facility, spreadsheets can be just as effective. Remember to update and back up these records regularly.

Editor’s note: Antonios is the CDI and ICD-10 physician advisor at Via Christi Health in Wichita, Kansas. A board-certified internist, he manages the hospital EHR system, works closely with quality leaders to tackle challenging documentation requirements, and engages with physicians on CDI and quality initiatives. This article is an excerpt from its original which appeared in the Sept./Oct. edition of the CDI Journal. Contact him at Samer.Antonios@via-christi.org.