July 15, 2021

Wrestling the Dragon

Avoiding Medical Denials When the Problem is Elusive

Written by Carl Byron, CHA, CIFHA, OHCC

In the first part of this series, we looked at a young patient in their early 20s who, in spite of 24- hour care by multiple specialties, died and all claims were denied in their entirety.

In this new case, we have a long-term inpatient who was attacked by an exotic animal a friend was keeping “as a pet.” Almost every specialty is called in on the case and the inpatient stay lasts well over a year. But during that time, after about 3 weeks of visits, Infectious Disease doctors stop billing for their services. They are worried with what little they have to go on that their claims will be denied out of hand “anyway.” They know the episode (the entire hospital stay once the patient is finally released) will be reimbursed on a limited basis and they would rather the payments go to the doctors with more detailed codes. For nine months, not one claim is filed. As you would expect, especially if you have seen any exotic animal attack cases that made the news, the damage to the victim’s body was immense and multiple large surgeries were required.

This time, the dragon is facing us and ready to charge. We don’t have to chase it, we know the problem. We have to wrestle it. We have to bring enormous complexity to a patient stay that has so many aspects, details and nuances that the argument for submitting the claims and getting paid is difficult because the patient’s condition is so poor the insurance company will have difficulty understanding all of the medical complexities. This is somewhat different than a pre-payment audit because the claims have not yet been completed. Infectious Disease (ID) providers, with decades of experience, are reluctant to file claims because of fear of denials and, by extension, accusations of fraud. Again, we are dealing with a problem. Although it is physically obvious, it is not so clear when reduced to codes which fall far short of the extent of the providers’ work to save the patient. The payor guidelines are equivocal and do not address a unique situation like this. But there is a statement that the medical decision making and clinical reasoning of the providers for any patient will be given primary weight. This is critical. Unless I can find something unique, the ID providers are stuck with only three procedure codes: 99231, 99232, and 99233. Not much room to maneuver.

My manager assigns me all of the ID claims and asks me to conduct a 100% records audit for the nine months. As in Part 1 of this series, the first thing I do is look at the progress notes. Due to the sheer volume, I determine (1) how many encounters there are total; (2) what would be a statistically significant sample number and then pull encounters from random dates throughout the hospital stay. Now the real work starts.

The first thing that strikes me is the enormous amount of damage done to the patient’s body. From the documentation alone, I could tell the damage was beyond anything I had ever seen. Extremely deep scratches were documented as well as punctures from fangs that tore through skin, muscle and tendon and literally shredded bones. Dislocated joints from being grabbed and pulled so hard the body could not tolerate the shearing forces. Grafts as well as vascular and orthopaedic repairs have to be done in “bouts” throughout the stay because the damage is so comprehensive the repairs cannot be done at one surgical visit. This is critical because it tells me even with gauze, coverings, etc., the patient’s underlying skin, muscle, tendons, blood vessels, lungs and even heart are in serious jeopardy of infection. A note was made and I proceeded from there. Inference tells me that, with so many surgeries completed and yet to be done, much of this patient’s skin and underlying structures are now open, even with the best suturing on the planet and antibiotics. Inference further tells me so many grafts present an infection potential of their own. Think of a paper cut: painful, obstinate, those things just don’t want to heal. Now, take that cut and make it into a long tear down to the bone and imagine 75%+ of your body area being torn, bitten, scratched or surgically open like that. You might get about a 5% picture of this patient’s daily situation. Just “maintenance” required a Herculean effort.

There are times when an auditor needs to let the inferences guide the direction of the audit, at least in part. Such was the case here, both with the documentation and with photos, and I will clarify it shortly. The next step, and I will admit I could be accused of changing my random audit to a targeted one, I looked for all the encounter dates I could find with photographs and x-rays. The photos were pretty gruesome but they displayed a very important fact: the opportunity for infection was always dangerously high. So, my first argument was made for me. Even if all ID did was maintain this patient, it was a serious accomplishment. It is said a picture speaks a thousand words. Those, coupled with the documentation, made an ironclad argument and I already knew we had a good chance.

As in Part 1, when I had assembled my audit structure and determined how I would proceed, I looked at every progress note. Then, I looked at every non-infectious disease progress note and another point showed itself: almost every note I read, referenced either reviewing the last ID note or speaking with the ID provider on service that day. Their evaluation on any given day was sought out even if it did not change from the previous day(s). So, as in Part 1, I contacted the providers. Again, they all agreed to meet but, due to the volume of work they did, they asked to include the Department Chair so he could fill in any blanks and keep me focused on ID-specific issues.

The meeting was eye opening. First, I let my inferences guide the opening of the meeting. If the damage to the patient was so massive, then perhaps smaller details existed to show the work these doctors and non-physician providers did. So I asked about how these providers dealt with labs. Turns out they almost lived in the laboratory; they relied on so many tests. The damage was so extensive that infection may not have been obvious on observation and the trauma to the skin went so deep the ID physicians needed lab tests to guide them every day. This is additional work and another argument when the claims are filed. Then came the biggest surprise, and the best details I may have overlooked if I had relied solely on the notes.

The providers started by telling me about how the deep bites, scratches, punches and open shearing wounds could cause infection in different ways, and even different infections. But these physicians were unfamiliar with many exotic animals and they had to make international calls to other countries’ zoos, biologists, veterinarians and animal experts to get help and advice treating this patient. These calls were made almost daily throughout the patient’s stay. But if information did not change, the providers only made a short notation in the progress note which could easily be overlooked.

Then, they took the photos and x-rays I brought with me and explained what they saw, what the photos meant, and how they drove their decisions at any given visit. They segregated specific labs and showed me what they looked for and why, in their medical judgment, so many had to be run. This was news indeed and the way the providers put it gave a detailed report I never could have arrived at without their assistance. As I mentioned earlier, other providers relied on their findings to determine how to proceed. This was also the case with the ID providers and they were in continuous contact with vascular surgery, orthopaedic surgery and especially reconstructive surgery and dermatology. The ID providers concluded by telling me that although the notes looked like maintenance-only treatment, because of the critical damage done to the patient/victim, they had to proceed with considerable caution because they were not the only specialty on this patient’s case. Every specialty had to make certain (as much as possible) that no other provider was negatively impacted by anything another provider did. This was an extreme learning experience for all of them.

Armed with this information, the only real difficulty I faced was putting the argument for payment together coherently and precisely. Every detail I could have wished for was in place. My manager allotted plenty of time but we were talking about nine months of claims for every day of the week. So my last possible hurdle was removed, thanks to a manager who wanted an accurate, complete audit. She reassigned my secondary duties to others on our team, even taking some herself. It was time to sprint to the finish line.

First, I printed a copy of the insurance company’s guidelines and where there were blanks (especially with inference) I pulled CMS guidelines. CMS allows inference if it can be clearly determined. This, coupled with the insurer’s statement that medical decision making of the provider will be given the most weight, made clinical medical necessity my focus rather than payor guidelines. As in Part 1, I still had to argue two types of medical necessity: why the doctors believed the patient needed treatment and did the treatments fall within the insurer’s guidelines.

Inference had shown me immediately that the damage and trauma to the patient was life-threatening. Inference from ID running so many labs was that the providers were either investigating something or making certain something was not showing up. Inferences from the documentation led me to know I had to get copies of all photos, x-rays and other very specialized procedures. When I did, the picture was so clear even a non-medically educated person could see this was an exceptional case. It also showed me how I needed to approach the most important medical necessity argument: why the providers did what they did, every day, every week, every month. With the information gained from meeting with the providers, every aspect of this specialty’s patient care became clear: the medical reasoning, the timing of procedures, everything. This is the value of inference and I never do an audit without it as a guideline.

The first was admittedly fairly easy. The risk of infection was so high that hour by hour oversight was critical to the ID providers and they not only had to prevent infection but they had to be ready to attack an infection from an exotic animal that the American medical field knew little about. Here is where I entered the evidence of so many international calls and constant consultations with other specialties involved. Then, I stated how after every surgery, and every surgery was major, the patient had to be cut open again. Next, came the extensive lab work and direct quotes from the meeting I had with the providers. Then, I tied it all together and made the photographs, x-rays, labs and other concurrent treatments separate exhibits. The photos especially were unnerving and separating them made them even more effective. Explaining what the doctors saw from the labs, x-rays, etc., and referencing them in a separate exhibit I believed also made them easier to find. This “pre-appeal” was going to be BIG. I completed my argument with information I gained at the meeting that I believed would be helpful.

Now for the codes. For the diagnoses, as with the examples in Part 1, they were not very specific and it could be assumed the payor would balk. I called the ID department chair back and asked him if he would be willing to have all of his staff involved (which was the entire department, as it turned out) review a few notes and give me some ideas. I had them within a couple of days. Since much of the treatment was prophylactic, meaning trying to keep infection from occurring, I reiterated the extent of the damage and specific statements made at our meeting. This showed the constant threat of infection and how, due to the mechanism of injury, it was not a well-known threat potential. I also used as many post-surgery and open wounds codes as I could because any area open to the air was a primary infection entrance point. Therefore, what might be misconstrued as maintenance was in fact treatment to stay on the offensive, prevent even the opportunity for infection to occur, and be ready to treat it immediately if any signs appeared.

Then came the procedure codes. This one was risky because I assigned every claim a 99233, the highest level allowed. Few additional procedures were done so my argument here was the elusive nature of the injuries and how difficult an infection could be to discover quickly. So many international calls to zoos, biologists and others; continuous consultations, even if informal, with other specialties to maintain a preventive stance on potential infections; and the need for so many labs to give an objective, data driven picture of the patient’s status. Again, I referenced the photo exhibits to give a very sharp picture to any reviewer that this patient was in dire straits and was constantly high risk for infection. Like one of the cases in Part 1 where I had a heated argument with a reviewer, I added a statement I would not necessarily recommend, but in special circumstances could be warranted. I closed this portion by stating it was unfortunate the highest the providers could bill was a 99233 because the work they did far exceeded any understanding of how the definition of this code was interpreted but, because of late filing, the ID department was willing to settle for this code alone. In addition, the department was willing to forego billing for the international phone calls (which is legal) for the same reason but, should the insurer balk, we reserved the right to appeal and these codes would be added for every call made. It was risky, but the case was so strong in my mind that I had to throw a final punch that I hoped would influence the claims in our favor.

I intentionally used the clinical-medical reasoning as my first argument. It was far and away the most important and it drove the codes I would recommend. In addition, it showed the patient and providers as people: a victim, and medical experts in their field with an extremely unique but serious injury on their hands. I do not recall the number of pages but I do know the file I sent to the payor was an inch thick. I made my Executive Report and met with my manager with the clear recommendation to proceed with claims submission. I further recommended, since the claims package was so large and required a physician knowledgeable in the finer details of my argument and results, that it be submitted directly to the insurer’s Medical Director. For the next three days it was raised along the flagpole. On the third day my manager told me every claim had been submitted. She told me that even she thought perhaps my requirement for everything going to the Medical Director was risky, because the medical reviewers and claims auditors might feel slighted and mistreat us in the future. At the same time, she saw the value of having another doctor have the first and last say in such high stakes (and high cost) medical treatments.

Shortly after, my manager received word that every claim had been submitted under the late filing guidelines at the insurer, meaning the claims were allowed similar to an appeal. All claims, arguments, statistics, reports, photos, results, etc., were allowed as one package. Every claim was accepted and reimbursement was promised.

I informed the Infectious Diseases Department and gave the chairman, as was his right, an electronic copy of my package for his review. Oddly, he called my director and requested a meeting just between him and I. My director called me directly, and I told my manager. She said, “Set it up.” Now, this is where I need to do some explaining. I also train healthcare auditors in quality assurance, or “why auditors need to be audited.” This chairman and I did not get along. I neither liked nor hated him but if I knew he was around, I avoided him. He saw my work as an irritation and if I reported any negative performance on his staff’s part he was sharp and fast in his critiques of my work. This could have caused a conflicting bias on my part, should I have been a QA or external auditor.

If I were auditing him or his staff, this argument would hold. However, I wore two hats in this organization. One was denials and appeals management; the role I was in here. The second was as an inpatient professional auditor, where I would audit the encounters of all departments including his. In my role here, it was imperative I believe in and trust the motivations and judgments of the providers. These providers had worked tirelessly and deserved every break allowable. Whether I liked an ID provider or not was absolutely irrelevant. Trusting them to act in the best interests of the patient was paramount. Being one person, yet both types of auditor, are not mutually exclusive. In this case, I was looking at the big picture rather than intricate technical details. I was looking at the good to the patient rather than data points and compliance to insurer guidelines which was secondary to why these providers acted and proceeded as they did. Auditing the providers for compliance is an ongoing process and should an insurer wish to challenge my audit based on this it is certainly their right. But in an appeal-type audit, I believe we shift focus from the technical physician to the wellbeing and survivability of the patient. Both can be done effectively as long as the auditor keeps these tenets firmly established in her or his behavior.

As it turned out, the chairman wanted to ask some details about the results and especially why I had the claims all submitted when the animal’s owner was being sued on multiple fronts and medical funds most likely had already run out. This is another priceless benefit of being an appeals auditor. I was able to tell the doctor that, as the funds ran out the lawsuit would inevitably go against the estate. He did not know this and promised he would forward the news to his staff. He thanked me for the work and told me he would be watching for the next audit rotation in his department, and we parted on good terms but quietly. Imagine my surprise when he requested my presence at another staff meeting. The chairman showed me to a seat up front and asked me to listen to the meeting.

I was not expecting the amount of information these providers had to take in at any given time and it became clear they wore a lot of hats. When they weren’t seeing patients in the office, they were seeing them in the hospital, or they were training new doctors, or they were getting documents ready for publication, or SOMETHING. Then, as the meeting closed the chairman told the group of our success with the animal attack victim and told the group they should thank me for my efforts. He also told them that in the future they needed to cooperate with me when they were audited and errors were found. I think every provider shook my hand before they left and I received congratulatory emails from them for the next few days.

A good auditor always learns and always strives to become better. With this one case, both the providers and I learned important new information. They learned that even if I audited them, I was trying to train them and improve their performance and was not an antagonist; I did have their best interests at heart. And I learned the doctors have an unbelievably difficult job and are constantly pulled in many directions; they deserve our respect. From that point on, if questions arose from an audit they met with me and we hammered out our differences to the point where Infectious Diseases became one of the most consistent, highest scoring auditee departments in the organization.

Carl is a subject matter expert consultant with the American Institute of Healthcare Compliance (AIHC) in areas of appeals, coding, auditing and investigations. Carl holds the following AIHC credentials: CHA, CIFHA and OHCC. Click here to learn about our Clinical Documentation Improvement course. For other courses and certifications, visit our Certifications Store: https://aihc-assn.org/certifications/


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