November 21, 2016

Fighting Clinical Validation Denials: Here’s How

In the first installment of this series of articles, Exasperation with Clinical Validation Denials (CVDs), I discussed what to do about such denials, which stem from legitimate concerns as to whether a condition is actually present for a patient. Honestly, I wish we had reserved that title for this final article in the series. It is maximally exasperating to deal with CVDs for which the condition is clearly present and the clinician produced adequate or exemplary documentation.

Let’s address a few egregious CVDs. Let me give you some examples:

Case 1:

Clinical information:

Stage IVA supraglottic carcinoma transferred from outside hospital for severe dysphagia, weight loss, and hoarseness, for surgery. Patient is noted to be on tube feeds for severe malnutrition with significant weight loss with overt muscle wasting, BMI 17.2, and low albumin.

Physical exam notes “malnourished, weak,” and dietitian consult concludes that the patient has severe malnutrition.


“Nutritional marasmus is not a valid diagnosis in this patient, who is status post-tracheostomy and a PEG presenting for further management of supraglottic cancer.” The auditor acknowledges all of the information above, with a cachectic appearance, but mentions that serum pre-albumin is not available. They reference the World Health Organization (WHO) criteria for adult malnutrition dating from 1999 as their source.

Case 2:

Clinical information:

Nasopharyngeal cancer, S/P radiation therapy and chemotherapy including cisplatin with creatinine going from 0.8 to 2.4. Renal consultant suspected “non-oliguric ATN (acute tubular necrosis) secondary to cisplatin nephrotoxicity” with recommendations for treatment. A later note referenced “now with AKI” and “polyuria secondary to post-ATN diuresis.” The attending physician had an impression of “ARF, likely cisplatin-induced.” Discharge summary reiterated the acute kidney injury, secondary to cisplatin.


“Although the renal consult felt the AKI might be due to ATN, the attending contradicts this, documenting that it was only AKI due to drug interaction.”

Case 3:

Clinical information:

Prostate cancer and frequent UTIs with “altered mental status,” described as “increased lethargy” and “confusion,” while also found to have dehydration, UTI, and rapid atrial fibrillation, which were all treated appropriately and improved. The impression was “metabolic encephalopathy from UTI and dehydration with acute-on-chronic renal failure.”


“Metabolic encephalopathy is not a valid diagnosis in this patient…encephalopathy is defined as reversible cerebral dysfunction resulting from metabolic disorders, organ failure, environmental exposure, or drugs. Objective documentation of encephalopathy requires documentation of alterations in cognition, impaired judgment, insight, or memory by mini mental status exam (or similar widely accepted tool for neuropsychiatric evaluation) at two points in time…EEG results were not available for my review. Neither neurology nor psychiatry was consulted. There are not MMS scores in the records that would objectively verify and quantify cerebral dysfunction. Documentation of specific treatments such as lactulose, chelation, exchange transfusion, or dialysis is not present….”

I hope your blood is boiling a little right now, and that you share my extreme aggravation over having to justify completely legitimate medical care and appropriate clinical diagnoses made by competent healthcare providers who were actually taking care of their patients. I viewed this type of denial as a supreme waste of valuable time, because they never should have been allowed to come to fruition, and it takes one to two hours to rebut each one. The irritation is compounded because my experience is that these denials are doomed to be upheld at least once, just because the auditors can. The system is rigged if the denier gets to process and adjudicate the appeal, especially when they are operating on contingency.

So the first step for each of these cases is to walk outside and scream aloud in frustration. Then, you have to walk back inside and tackle the denials point by point. There are certain recurring themes in blatantly preposterous denials. 

First of all:

  • The auditor doesn’t understand the coding. 
    • I had auditors who would try to take away “acute renal failure, unspecified,” because the patient only had “acute kidney injury.” For those of you who don’t get why this is absurd, there is no separate code for AKI (yet), meaning you must use the code for acute renal failure.
    • There was an example of an auditor informing me she was removing severe malnutrition despite it being documented four times in the patient encounter record, and that she was replacing it with the code for moderate malnutrition based on the BMI (using WHO criteria). A condition can’t be coded based on clinical indicators if the provider has not documented it as such, so if no provider has documented “moderate malnutrition,” a coder can’t autonomously apply the qualifier of “moderate” to the diagnosis.
    • I have seen auditors eliminate uncertain diagnoses found in the discharge summary, apparently unaware that an uncertain diagnosis that has not been ruled out by the time of discharge or demise gets coded as though it were definitively present. An example that comes to mind is “suspected bacterial endocarditis,” wherein the blood cultures were positive for Enterococcus faecalis, but vegetations could not be demonstrated because the patient was unable to undergo a transesophageal echocardiogram.
    • In the example above, the patient had a prosthetic valve. The auditor wanted us to remove the endocarditis and make the principal diagnosis infection and inflammatory reaction due to cardiac device, implant, and graft. What did they propose the infection was, if they were removing the suspected endocarditis?
    • Inappropriate resequencing: I had a case in which a patient came in with Clostridium difficilePOA-Y and developed sepsis on the fourth day (POA-N), and the auditor wanted to re-sequence the sepsis as the principal diagnosis.
    • In Case 2 above, there was no contradiction between the renal consult and the admitting physician. This was an example of the auditor not understanding the concept of linkage.
  • The supposedly clinical reviewer doesn’t understand the medicine. 
    • In Case 2, approximately 40-45 percent of AKI in the hospital is caused by ATN. ATN often occurs due to nephrotoxicity. These are not mutually exclusive conditions; they are related.
    • I have many examples of auditors trying to remove sepsis “because the patient has an alternative diagnosis of pneumonia (or cellulitis or UTI).” Sepsis occurs as a result of that underlying infection; again, they are not mutually exclusive conditions.
  • They are using outdated criteria. 
    • Case 1 demonstrates this. The 2012 Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Undernutrition) is a much more appropriate reference to use for malnutrition, as compared to the WHO criteria from 1999. Specific inflammatory markers, such as pre-albumin, have been debunked as a criterion for malnutrition.
    • I have seen many AKI cases for which the 2004 AKIN criteria were being used, as opposed to the more current 2012 KDIGO criteria.
  • They are misunderstanding or misapplying the criteria. 
    • I handled a denial for shock liver that had an episode of profound hypotension followed by markedly elevated AST and ALT, wherein the auditor cited an article that mentioned a rise in LDH. Since no LDH was performed, the auditor denied the condition of shock liver.
    • I had numerous cases in which the clinical reviewer tried denying sepsis cases, stating that the patient didn’t meet SIRS criteria, whereas the patient met multiple general variable and other criteria (inflammatory, hemodynamic, organ dysfunction, or tissue perfusion variables, as per Surviving Sepsis Campaign,2012) at multiple points during their hospital course.
    • It is common practice for auditors to deny sepsis claims because the blood cultures are negative, or there is no known infection. Sepsis is due to a presumed or confirmed infection. Blood cultures do not have to be positive; you can have a fungal or viral sepsis, you might draw blood cultures on antibiotics, or you just may miss capturing the organisms’ circulation in the bloodstream.
  • And number one on my most exasperating list: they are just making stuff up! 
    • For Case 3, there is no evidence or guidelines indicating that you must perform a mini mental status examination on two separate occasions, or you can’t diagnose encephalopathy. You do not need to do an EEG. You do not need a neurologist or psychiatrist to assist you in making the diagnosis of encephalopathy.
    • I had examples wherein the auditor would state that since the encephalopathy or the respiratory failure or AKI was transient and resolved with prompt, aggressive, appropriate treatment, the condition was not valid.
    • I had cases in which an auditor suggested that a patient needed to have some invasive, extensive, expensive workup in order to be entitled to diagnose AKI.
So, what to do?

  1. First, read the denial carefully. Determine what issues upon which they are basing their denial.
  2. Next, read the medical record and collect the support to refute the denial point by point. This is also the time to collect your material for your provider feedback, as I discussed in my last article.
  3. Familiarize yourself with their criteria or guidelines. If it rankles you that they are using outdated criteria, find more current, appropriate criteria and provide it to them as an attachment. Reference the “standard of care.” Research up-to-date literature that is relevant.
  4. I don’t recommend having a boilerplate appeal template, other than the very introductory paragraph, in which you assert that you are appealing, and your final paragraph, in which you ask them to reverse their decision and contact you for further information if needed. I think each rebuttal needs to be unique, and specific to the denial.
  5. Make sure you understand the coding implications sufficiently. You may want to discuss the case with a knowledgeable coder or clinical documentation improvement (CDI) specialist to be sure you understand what the denial is based on and to be sure that you are following coding guidelines.
  6. Now, articulate where you disagree with their denial, point by point. Quote from the electronic medical record. You can even copy-and-paste and change the font, indent, and highlight index phrases to make it more readable. You are trying to give them an alternative narrative, so you do not need to only display the exact verbiage. Take a look at Case 3 above to see what I mean. Even if they didn’t call it out as “encephalopathy” in every progress note, referencing “altered mental status,” “acting strangely,” and “confused” is supportive. Grab pictures of lab trends when appropriate and embed them into your denial response.
  7. Check out the auditor/payer’s website and look for their policies on ethics, fraud, waste, and abuse. If they suggest you do inappropriate testing, reference their own ethics policy: 

    “I know your own ethical guidelines regarding fraud, waste, and abuse dissuade providers from taking actions that would result in overutilization of services or other practices that would increase cost or prove to be medically unnecessary, so I know you are not suggesting that we have to call inappropriate, medically unnecessary consults if we feel comfortable handling the condition primarily. Lactulose, chelation, exchange transfusion, or dialysis would be appropriate only in very specific types of encephalopathy (hepatic, toxic, and uremic), not general metabolic.”

  8. Use analogies they should be able to understand. Try to be respectful and avoid expressing your irritation (do as I say, not necessarily as I do!).

    I had a case in which the patient had such horrible malnutrition that there were pressure sores on their spine. The wound nurse had taken photos, and I was confident that anyone viewing those pictures would make a diagnosis of severe protein-calorie malnutrition. I recommended that if the reviewers were not sure, they could remove the PHI, show the janitor the pictures, and ask him if he thought this patient had severe malnutrition.

    “This patient was on mechanical ventilation (noninvasive positive pressure ventilation) upon arrival, consistent with respiratory failure. The fact that she was able to be weaned quickly off of it is a testament to the aggressive treatment she received prior to and upon arrival. However, concluding that she didn’t have respiratory failure is analogous to a woman delivering a baby in the ambulance and saying she doesn’t need to go to labor and delivery because she is not pregnant upon arrival at the hospital.”

  9. Conclude with a recap as to why you believe the condition really existed and was adequately documented, plus why the denial should be overturned and how you think the coding should be either maintained or changed. I would say 10 percent of the time, one of the conditions that the auditor removed was legitimate, but the other conditions proposed for elimination should not have been removed; there were other diagnoses that were overlooked and should be added; or that there was resequencing that I felt was indicated.

  10. After you have exhausted your written appeals (usually two), for the cases of grossly unfair denials, request they escalate you to a peer-to-peer review. Hopefully you will be able to convince a reasonable physician of the merits of your arguments.

  11. The last resort is the administrative law judge (ALJ) level. I do not know how many institutions actually go to this level, but there is a huge backlog, so there must be plenty of facilities and systems that refuse to let it go. I never got to that level, although I had cases that I certainly would have supported for consideration.

  12. Be organized and keep a spreadsheet of CVDs. You should keep track of when you receive the initial and follow-up denials, who the auditor/reviewer/peer reviewer is, what the timelines are, if denials get overturned, and if you decide not to appeal because you agreed with the denial. Note the submitted and proposed DRGs, relative weights, and monetary impacts. If you get cases overturned, those should be attributed to your ROI (return on investment).
Categorize the reason for the denial (e.g., most common diagnoses, like AKI, malnutrition, and sepsis). Keep track of the feedback you dole out, and to whom. If there is a problem provider, perhaps he or she needs some intensive private education. If there is a problem service line, perhaps they need a directed presentation. If there is a problem auditing entity, perhaps you need to get contract management involved.

The good news about fighting clinical validation denials that are clearly unjust is that it does get easier as you get more familiar with the system and the clinical guidelines. The bad news is that until there is reform of the system, the auditors will continue to benefit financially from generating denials, and they are going to keep doing it. 

The healthcare system is expending a lot of time and energy trying to take back money we already had been reimbursed, for care we already had provided. It’s time for us to be able to go back to taking excellent care of our patients. I hope this helps. 

Good luck!

EDITOR’S NOTE: Register now to attend Dr. Remer’s webcast on HCCs and outpatient risk-adjustment with case studies on Thursday, Dec. 8, 2016 at 1:30 p.m. ET.
Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As Physician Advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July, 2016. Dr. Remer is a member of the ICD10monitor editorial board and co-hosts Talk Ten Tuesdays.