FairCode Advice on Avoiding Review Organization Denials

FairCodeAssociatesReview organizations (RO) tend to reject an uncertain diagnosis that is documented as suspect during a hospital admission even though official guidelines direct ROs to “code the condition as if it existed or was established. The basis for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.” However, ROs feel entitled to reject the code if:

  • The expression of uncertainty is not explicitly documented on the discharge summary.
  • Any secondary diagnosis code that does not meet UHDDS/ICD-10-CM criteria for a reportable secondary diagnosis.
  • A reportable secondary diagnosis affects patient care by requiring clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care or monitoring, or has implications on neonates related to future health care needs.
  • ROs state that abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

Codes can be proactively supported in the following ways:

  • Cite MR documentation indicating need or plan for follow-up after discharge.
  • Query the physician if the diagnosis is supported by clinical indicators but not explicitly stated on the discharge summary.
  • Include in case notes any documentation that helps the diagnosis to meet UHDDS/ ICD-10-CM criteria for a reportable secondary diagnosis.

Contact Kevin O’Neil at koneill@faircode.com for more information.