When Your Payor Disputes Coding Accuracy

Many providers have experienced a significant increase in clinical validation denials, citing lack of coding accuracy. This is a specific denial category that occurs when clinical evidence in the patient chart is inadequate to support a billed diagnosis. It is not the same as coding, billing or charging errors. It is important to understand the cause of these denials and develop strategies to improve the process. For example, if the provider documents Acute Respiratory Failure, the chart should include ABG values, whether the patient has chronic respiratory compromise and evidence of aggressive measures of oxygen intake. Documentation that is lacking in these areas may lead to denial of the claim. Regardless of your setting, it is important to quickly identify these denials and work with your providers to adequately support conditions documented in the record.

Historically, coders have relied upon provider statements when coding for conditions managed in the current encounter. Recent payor trends of claims review have identified coding and documentation patterns in which provider statements did not contain supporting information necessary to validate the condition and how it was managed.

In this webinar we will discuss several examples that will explain how and why providers are seeing these significant increases.

Webinar’s Goals

• Ability to identify clinical validation denials & coding dusputes and why they occur.
• Understand that diagnostic statements by the provider require supporting evidence of the condition. Can be compounded when the provider is selecting codes.
• Conflicting provider opinions that are not addressed can contribute to denial activities.
• Understand that payers often have specific diagnostic protocols that include expected clinical criteria.
• Review examples of clinical validation denials and common expectations that should be in the record.

Areas Covered

• Recognize denials associated with clinical validation.
• Review your top 5-10 denial categories and analyze these claims for patterns with certain diagnoses. What is missing that would support the billed condition?
• Query providers when diagnostic statements are not clearly supported with clinical evidence.
• Develop provider education opportunities for stronger evidence of the billed diagnoses. Education can include other departments for better outcomes.
• Education should include the financial impact of documentation deficiencies and inconsistences.

Target Audience

• Revenue Cycle Managers & staff
• Billers
• Coders
• Clinical Documentation Staff
• Finance Managers
• Denial Management Staff
• Physicians
• Mid Level Providers
• Claims Follow Up Staff