Q&A: Denial trends and CDI involvement
As part of the 14th annual Clinical Documentation Integrity Week, ACDIS conducted a series of interviews with CDI professionals on a variety of emerging industry topics. Lori Ganote, MSN, RN, CCDS, system director of clinical documentation integrity at Baptist Health System in Indiana, answered these questions with contribution from Coral F. Fernandez, RN, CCDS, CCS, system CDI auditor/educator at Baptist Health System in Indiana. Fernandez is a member of the ACDIS Furthering Education. Though CDI Week 2024 has now past (September 16-20, 2024), ACDIS wanted to continue highlighting additional expert advice from our committee over the next few weeks. For questions about the committee or the Q&A, contact ACDIS Editor Jess Fluegel (jess.fluegel@hcpro.com).
Q: When asked who in the CDI department is involved with the denials management/appeals process, 41.67% of respondents said the team leads/managers, followed by 29.17% who said a designated denials or appeals specialist in the CDI department. Who on your team is involved with denials management and/or appeals, and what is their role like?
A: At Baptist Health System, the appeals nurses write the response to clinical denials. The appeals nurses are a part of the CDI department and provide individualized feedback to the CDI specialists. They also share information on trends in denials and what criteria are most often being cited by the insurers/auditors. Because they are all members of the CDI team, they are able to understand more than one side of the issue and have maintained their strong working relationships and effective communication with members of the CDI team.
Q: Clinical validation was the most common type of denials that CDI programs are involved in, chosen by 85.54% of respondents. The runner-up was DRG validation, chosen by 54.66% of respondents. What types of denials does your CDI team help with, and what advice do you have for CDI programs looking to get involved in these types?
A: While our appeals nurses write responses to clinical appeals, denials based on DRG validation are addressed by the coding department. My advice would be to read every denial carefully, review the references used by the insurer/auditor to support their contention, and continue to appeal if you have a sound argument. Do not assume that information in the denial is accurate. Communicate with the CDI specialists regarding trends and celebrate or acknowledge when the work of CDI or a particular CDI specialist made a difference in the outcome of an appeal.
Q: More than 85% of respondents reported that sepsis is one of their top five denied diagnoses, followed by 74.02% who said respiratory failure was in their top list (a significant jump from 2023, when 64.56% said respiratory failure). Have you noted an increase in respiratory failure–related denials in the past few years? Why do you think these two diagnoses pose such a denial risk? What types of diagnoses do you see most frequently denied, and how have you worked to fight against those denials?
A: The reason for sepsis posing a denial risk is that some payers use Sepsis-2 criteria and some use Sepsis-3. The Office of Inspector General is currently working on sepsis. As far as respiratory failure being increasingly denied, denied diagnoses at our organization are not significantly different from other entities as far as I have noted—sepsis, acute respiratory failure, malnutrition when specified by degree, etc. Our CDI specialists use a second-level review process for some diagnoses, meaning the encounter is reviewed by a second CDI specialist to offer their opinion.
Q: The most common denial mitigation tactic was clinically validating high-risk diagnoses concurrently (42.55%), followed by reviewing denials on a case-by-case basis upon request (41.61%). 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: Our CDI specialists perform clinical validation on a variety of diagnoses during their encounter review. I think the most effective use of a CDI specialist’s time is to do exactly this. Regardless of access to denial volumes in their particular facility, the most often denied diagnoses are very similar nationwide and should be easy to identify.