Clinical Validation Denials and Appeal Management

Course Description:

Many providers have experienced a significant increase in clinical validation denials. 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.  

Learning Objectives:

• Ability to identify clinical validation denials 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 in the Session:

• What is Clinical Validation?
• RAC Statement of Work Medicare Program Integrity
• Medicare Program Integrity
• DRG & Clinical Validation
  • DRG Validation – CMS
  • Clinical Validation – RAC SOW
• Clinical Validation
• Prevention
• CDI & Coding Collaboration
• Types of Medicare Reviews
  • Automated Review
  • Non-Medical Record Review
  • Medical Record Review
• Identify Educational Opportunities & Process Improvement
• Are Your Denials Getting Worse?
• Patient Financial Services
• Examples - Reasons For Claim Denials
  • Sepsis-Severe Sepsis (R65.2-)
  • Acute on Chronic Respiratory Failure (J96.2-)
  • Encephalopathy (G93.4-, G92.8-, G94)
  • Acute Blood Loss Anemia (D62)
  • Congestive Heart Failure (I50.-)
• Documentation Inconsistencies
• Process Improvement

Suggested Attendees:

• Revenue Cycle Managers & Staff
• Billing Manager
• Billers
• Coders
• Clinical Documentation Staff
• Finance Managers
• Denial Management Staff
• Physicians
• Non-Physician Providers
• Mid Level Providers
• Claims Follow Up Staff

About the Presenter:

Dorothy D. Steed, MSLD, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACS-OP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CRCR, CICA, CPAR is an Independent Healthcare Consultant and Educator in Atlanta. She has served as Medicare specialist and a physician audit supervisor for hospital systems with 46 years of experience in healthcare. She is an instructor at a state technical college in Atlanta and provides auditing & training in both facility and physician services. She is credentialed in medical coding, medical billing, medical auditing, utilization management, healthcare management, healthcare compliance, clinical documentation improvement, revenue cycle and patient accounts. Additionally, she has participated in multiple healthcare audits and investigations for both plaintiff and defendant.    

Additional Information:

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to hear clearly
• For more information, you can reach out to the below contact:
  Toll-Free No: 1-302-444-0162
  Email: care@skillacquire.com

Snippet From Our Previous Session:

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1. Medicare Advance Beneficiary Notice (ABN): 2023 Updated Rules and Guidelines
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