March 14, 2018
12:00 PM – 1:00 PM ET

Are coding denials by insurers such as Humana, Aetna, Blue Cross now taking over your time or the time of your denials management staff?

Clinical validation denials are now widespread and intrusive. Many of the targeted diagnoses have been documented clearly and consistently in the medical record but do not meet accepted published clinical indicators.

Official coding advice directs coders to code diagnoses that are documented by a physician as long as there is no conflicting documentation. Is the fact that the clinical “information” contained in the record does not “confirm” the diagnoses documented by the provider enough to remove the code(s) from the claim and pay the claim under a different DRG?

We have reviewed and appealed hundreds of such denials. We will share with clinical documentation improvement team the diagnoses receiving the most denials and clinical criteria used to make the denial. We will share our findings, successful appeals and those that were unsuccessful and why.

Concurrent clinical validation of the principal diagnosis, and CC/MCCs which determine the MS-DRG by CDI is necessary to ensure the documentation in the medical record supports the codes assigned thereby preventing future clinical validation denials. Learn how to compose physician queries that will obtain the clinical indicators to support or rule out a diagnosis that is not appropriate.

Program Objectives

• Understand difference between DRG validation and Clinical validation.
• Understand evidence-based clinical practice guidelines and how third party payers are using them to generate coding and/or DRG changes.
• Describe basic content of appeal letters and timely submission requirements.
• Develop internal tracking mechanisms to identify coding/DRG change denials and appeals.
• Discuss sample issues/cases involving coding/DRG changes due to clinical validation and/or documentation issues.

Speakers: Ms. Barbara Flynn, RHIA, CCS and Ms. Silvia G. Ortiz, MSHSA, RHIT, CMPSM