Payer Used 2003 Coding Clinic to Decrease Reimbursement

Original story posted on: July 10, 2019

Coding Guidelines and Conventions trump Coding Clinic.

Hats off to coders. 

This group of medical information professionals is required to master one of the most convoluted and confusing set of rules known to civilized man in order to categorize hospital services and submit their findings to insurance companies for billing.

As physician advisors in clinical documentation improvement (CDI), our job is also to master these rules, and to assist coders in crossing the clinical checkboxes off as they go. There is clearly a language chasm at times, and capturing the correct codes to accurately reflect our patients’ severity of illness (SOI) and risk of mortality (ROM), as well as to ensure fair reimbursement for services rendered, can be a challenge.

Presumably, those on the other end of the transactional process also study and attain mastery in the rules of coding, so that they can monitor our efforts and, when appropriate, start a robust, informed discussion when disagreements arise. Occasionally, a payer will demonstrate a lack of knowledge of coding rules, or even send a denial wherein the argument contradicts a previously firmly held stance on coding a diagnosis. And once in a while, within the same denial, they will do both. A recent posting on Recovery Audit Contractor (RAC)relief by Dr. R. Phillip Baker detailed the issues of coding rules involved when both acute kidney injury (AKI) and dehydration are present on admission and established to be coequal diagnoses.

The DRG payment is higher for dehydration as the PDX. This is, in part, because AKI acts as a complication or comorbidity (CC) to the dehydration PDX, and the reverse is not true.

Dr. Baker points out that in this particular case, the patient’s creatinine level just barely made acceptable criteria for AKI. He further noted that this same insurance company had in the past (with the same creatinine level variation) denied that AKI was present in a patient. However, in this case not only did they assert that the patient had AKI, they insisted, based on a Coding Clinic from 2003, that the AKI must be sequenced first. This change would lead to lower reimbursement for services rendered. It also markedly changes both the SOI and ROM from a level 3 to a level 1.

One very useful result of this denial is that Dr. Baker now has in black and white, on the letterhead of this payer confirmation, that they believe that this patient, with the stated variation in creatinine levels, does indeed meet the diagnosis of AKI. No doubt Dr. Baker will use this as a powerful reference for future denials of this diagnosis from this payer.

It is also useful to take a step back and consider the citation the payer used to deny the claim. Again, it is from a Coding Clinic published in 2003. I would like a show of hands from those who would stand up in morning report or cite in a consult note a reference from 2003 on criteria for acute MI, sepsis, malnutrition, etc. Just as the medical literature changes over the course of a decade and a half, so too do the coding rules. In 2003, we were more than a decade away from ICD-10. Times have changed.

It turns out that there is a Coding Clinic on this very topic from January 2019. This coding clinic states that:

“The sequencing of dehydration and acute kidney injury (acute renal failure) should be based on the reason for the admission. Query the physician regarding the principal reason that the patient was admitted, if the reason for the admission is not clearly documented. There is no rule that acute kidney injury should always be sequenced first.”

Given this updated reference, I hope Dr. Baker has had the opportunity to begin a discussion with this payer on recent changes in the Coding Clinic rules, with respect to the sequencing of dehydration and AKI.

Unfortunately, it is not unheard of for payers to exhibit incomplete or inconsistent reliance on coding rules. As a CDI PA since 2014, I have seen payers use outdated rules, incorrectly applied rules, seemingly deliberately misconstrued rules, and, as with the AKI instance above, a pattern of denying the rule most of the time and citing it when it suits their case.

So, where do we start? We start by knowing the rules. We need to know that Coding Guidelines and Conventions trump Coding Clinic, and that the alphabetic index trumps these, and  that the tabular index trumps all. It’s important to know that “and” means “and” or “or!” If a denial cites a reference, check it out. It could be outdated or taken out of context. Just as we would view with skepticism clinical judgment based on outdated criteria, we must bring our skepticism to the citation of old coding literature and references.

And remember to be kind to your coders, especially since they can help you navigate the coding rules matrix.


Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDS is a graduate of the University of Maryland School of Medicine with a Masters in Management of Clinical Informatics from Duke University. She works full time as a physician advisor for CDI at Vidant Health and still does clinical shifts as well.

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