Guest post: Win the “Game of Denials” by turning the debate to clinical facts

CDI Blog - Volume 13, Issue 48

by Howard Rodenberg, MD, MPH, CCDS

Every job is a learning experience, and I learned more than a few things during my tenure as a county and state health director. One was that when you shake hands with someone, always say “Nice to see you.” If it’s the first time you’re meeting someone it’s a fine greeting, but it also covers you if you’re met the person before and simply don’t remember.

Another was that in order to make legislative progress, everyone involved needs to accept there’s a problem before a solution can be found. That’s best done by reframing issues in a different context, most often by using mutually accepted facts. For example, if we want to ban indoor smoking, we could phrase the argument as such and run into a buzzsaw of individual rights and the economic effects on small businesses by limiting tobacco sales. Or we could start by noting that smoking causes lung cancer and emphysema, and costs millions in healthcare expenditures, so how can we improve on that? It’s okay to differ on what to do about the problem, and much easier to drive positive change, as long as we have a common understanding of what the problem actually is.

Unfortunately, we’re now in an era where facts, if and when they exist, are considered malleable; where every opinion, no matter how unfounded or counterintuitive, is granted equal value and importance; and where the electronic revolution gives air time to every thought within their echo chambers. There’s no question that the new authority of opinion over facts has harmful to our national dialogue.

So is it any wonder that the latest tactic in the Game of Denials dismisses fact for opinion? In the last few months, I’ve run across a new phrase at the end of second- and third-level denials. The first denial letters still tend to focus on facts, or (more likely) some misinterpretation of them. The higher-level denials, however, understand that while facts can be argued, opinions can’t. And so opinion becomes the reason for denial, using phrases such as “clinical evidence and resource impact for this condition is not reflected with the medical record for this encounter,” or simply a statement that the diagnosis is not clinically appropriate without any criteria presented at all.

What exactly does that phrase mean, and how is it used in denials? It’s kind of like an old joke about lawyers, in which a young person asks a lawyer what “justice” means. The attorney replies, “What do you want it to be?” Clinical evidence and resource impact are what the claim reviewer says it is, and that’s the beauty of the phrase (I must confess with grudging admiration.)

“But wait!” you say. Physicians wouldn’t write something on the chart unless it mattered to them clinically, and coding/CDI professionals wouldn’t enter a principal or secondary diagnosis into the medical record unless it met the official definitions. Of course, you say, the diagnosis is supported.

That would be true if those who reviewed the case were bound by the same rules that govern the ethics of CDI and coding. But as the AHA Coding Clinic, Fourth Quarter, 2016, makes clear in its discussion of clinical definitions, payers are not bound by the same rules. An additional consult, scan, or lab test used to evaluate or monitor a problem may not meet their standard of evidence for the presence of a clinical condition. And because these are vague, undefinable criteria, based on opinion and not amenable to a discussion of fact, these are battles you cannot fight simply by proving that their interpretation of the medical record is simply wrong.

What I believe you can do is recognize that in denials world, we’re playing the long game. Our real audience isn’t the payer, but those outside the provider-payer dyad who might eventually be involved in resolving the conflict and to whom facts matter, such as a legal counsel, a judge, or a mediator.

So how do we reframe opinion into a difference of opinion regarding the facts? In these cases, I believe that’s done by not arguing the minutiae of an individual case. Doing so simply leads down rabbit holes. Was that extra complete blood count really needed? Did anything change because you got the CT scan? How bad can the malnutrition be if all they got was an assessment and a can of Ensure? Did the patient’s frailty really change the length of stay?

Arguments such as these can never leave the realm of opinion. But we can reframe this as a question of fact by taking a larger view, that not only is the diagnosis supported within the medical record, but more importantly that the presence of the diagnosis in and of itself carries significant implications for clinical care of the patient.

Here’s an example of what I mean. Last month we received a second-level denial for the diagnosis of malnutrition. Some of the arguments were familiar, noting that the patient received solely oral supplements as treatment. (We’ve addressed these kinds of claims in prior ACDIS Blogs.) But the letter also used the phrase cited above as a new contention supporting the denial.

We had previously done an extensive literature search addressing the clinical outcomes of malnutrition as we developed our ASPEN-based institutional definitions of the condition. So we were ready to contest this response with not only supportive diagnostic criteria, but more importantly with a set of references clearly documenting that the simple presence of malnutrition exerted a myriad of negative effects on morbidity, mortality, wound healing, respiratory status, length of stay, and hospital charges. Using the literature in this way may defuse the “clinical and resource impact” argument; if not in the immediate process of appeal, at least to those who eventually matter.

It's my thought (because I hesitate to use the word “opinion”) that this broader view can help support similar appeals. I’m certain that with a modicum of effort the CDI community can assemble referenced literature reviews for common subjects of denial such as acute kidney injury, sepsis, acute respiratory failure, and malnutrition that demonstrates the inherent clinical and resource requirements of these diagnoses.

And don’t neglect your own intra-facility claims records as a source of information. We were able to demonstrate, using in-house data, that in patients with morbid obesity, the simple presence of the condition was associated with longer length of stay and increased hospital charges when compared with same-DRG peers, regardless of specific assessment or treatment of the condition. The details of our work were published in the winter 2019 issue of Perspectives in Health Information Management.

Take the time to work with your physician advisor to develop these supportive documents. Reframing the discussion shows who’s really working with the facts, and who is working on behalf of the patient.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at or follow his personal blog at Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.

Found in Categories: 
Denials & Appeals, Education