To Appeal or Not
to Appeal?
The Art of Responding
to External Coding
Audits
Carol Kerr, RHIA, CCS
OrHIMA Fall Institute, 2014
Audit “Truths”
• They are going to happen.
• The auditor is not always right.
• There are resources to help:
– AHA Coding Clinic
– ICD-9 Official Guidelines
– Briefings of Coding Compliance Strategies, HCPro
– Getting It Right Upfront: Inpatient Documentation
and Coding, RACmonitor, MedLearn publishing.
• A well-written response letter can be very
persuasive.
Coding “Truths”
• Coding professionals know that coding is not
black and
– there is room for
interpretation.
• Coding is much more of an art
than it is a science.
• There is subjectivity in coding, so you can have
two coders code the same
encounter differently.
Types of Coding Denials
• Principal Diagnosis
Validation
• Secondary Diagnosis
Validation
• Procedure
Validation
Coding Scenario 1
• 67-year-old patient presents with SOB, diagnosed
as acute diastolic heart failure – principal
diagnosis. Audit finds that secondary code of
750.3 should not be coded, resulting in lower
reimbursement.
• Past medical history lists “Schatzki’s Ring” – not
specified as acquired so code 750.3, Esophageal
Fistula, Esophageal Atresia and Stenosis,
Congenital, is reported as a secondary diagnosis,
which is an MCC.
• Appeal or not to appeal?
• Lessons to be learned?
Coding Scenario 2
• Patient admitted with SOB; imaging shows
CHF with mild pulmonary edema and trace
pleural effusions. Code 428.0 is coded as
principal diagnosis.
• Audit findings state that due to above
documentation code 511.9, pleural effusion,
should be reported, changing the DRG for
increased reimbursement as 511.9 is a CC.
• Appeal or not to appeal?
• Lessons to be learned?
Coding Scenario 3
• Patient presented with abdominal pain with
associated nausea and vomiting and diagnosed
with mesenteric ischemia; patient also has AKI,
anion gap metabolic acidosis, and diabetes, not
well controlled. Audit finds that code 250.12,
diabetic ketoacidosis (which is an MCC), is not
supported by the documentation and should be
changed to 250.02, resulting in a decrease in
reimbursement.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 4
• Patient admitted with acute diverticulitis with
diverticular abscess per the H&P; post-op findings
were diverticular abscesses x 2, sigmoid and
descending colon, with contained abscesses in the
mesentery; the op report states, “The patient's
descending colon from its mid portion down to the
rectosigmoid junction were essentially bound very
tightly to the retroperitoneum. Beneath this
retroperitoneum were 2 abscess cavities denoted by
preoperative CAT scan. This mobilization was very
careful along the line of Toldt and the ureter was
visualized and protected throughout the case. The
mesentery supporting the segment of bowel where
the abscesses were was ligated and divided using 0
Vicryl sutures.”
Coding Scenario 4, cont’d
• Audit findings were to revise 567.22 (an MCC),
peritoneal abscess, to 569.5 (a CC), abscess of
intestine, stating, “While we agree the
resident progress note documents an intraabdominal abscess this abscess is further
specified as a diverticular abscess in the
additional progress notes, operative report
and discharge summary. Please refer to the
ICD-9 alphabetic index for Abscess, Intestine
that leads to code 569.5.”
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 5
• Patient admitted for partial revision of knee
replacement (tibia component); audit finds
that 285.1, acute blood loss anemia, and
345.80, other forms of epilepsy (both CCs)
should not be coded. Anemia is documented
in postop progress notes; remote history of
seizures documented on anesthesia record
and patient is on Klonopin.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 6
• Patient admitted with an acute DVT and
documentation of CKD Stage IV, 585.4 (a
CC); audit finds that clinical indicators do
not support a diagnosis of CKD Stage IV,
but CKD Stage III, so code should be
changed to 585.3 for a decrease in
reimbursement.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 7
• Patient presented with SOB, diagnosed with pneumonia in the
ER and admitted. The H&P states, “I think that this is acute
CHF, not pneumonia but Pro BNP is pending and we are
noting the response to IV lasix. I am not impressed that the
CXR is any different than the last one 3-2013 which was when
had had and EXACERBATION OF CHF ALSO.” The discharge
diagnosis is systolic CHF, acute on chronic and documents, “He
was given ceftriaxone and azithromycin by the ED, but after
40 mg lasix once, he diuresed almost 2 liters and felt much
better with O2 sat over 90 on RA, This in combination with his
proBNP of 2129 and a CXR looking just like the one from
March 2013 when he had CHF convinced me that the main
problem is acute decompensation of his CHF. I decided not to
continue the antibiotics.” Audit finds that 486, pneumonia,
should not have been coded as a secondary diagnosis.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 8
• Patient admitted for GIB and found to have an
angiodysplasia of the intestine with
hemorrhage; H&P documents an atrial septal
defect and refers to a “cardiac shunt” and
“secundum ASD” on TEE earlier in the year;
ASD also documented on anesthesia record
and ASA score is 4. Audit finds that code
745.5, for the ASD, should not be coded
stating “per the HP the patient has had
previous cardiac shunt surgery for the ASD
and therefore this diagnosis would not be
collected as a secondary diagnosis.”
Coding Scenario 8, cont’d
• Patient has documentation of a CABG and
pacemaker implantation in current chart; the
echo referred to in the chart states, “2D echo
and color Doppler findings are consistent with
a secundum atrial septal defect with
bidirectional shunting, although
predominately left to right. The superiorinferior dimension of the ASD was 0.4 cm.
There was a right-to-left shunt at rest by
contrast study with agitated saline.”
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 9
• Patient admitted with neutropenic fever
(288.04); also has AML and pancytopenia
(patient has had chemo). Audit finds that
reported code, 284.69 (an MCC), aplastic
anemia is not supported by documentation, as
the pancytopenia is documented as
“transfusion dependent,” so code should be
284.19 (a CC).
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 10
• Patient admitted with chest pain (determined
through a coding query to be a continuation
of a previous NSTEM so coded with 410.72).
Also coded, based on a coding query, was
428.41, acute combined systolic & diastolic
heart failure (an MCC). Audit finds that
428.41 should not be coded as there are no
clinical findings to support this diagnosis.
There was a coding query asking for specificity
for the heart failure (query gave choices) that
was documented in the H&P, but in no other
place.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 11
• Patient presented to ER with AMS, found to be most likely
due to hypoglycemia and hepatic encephalopathy . . . “no
obvious acute precipitant although liver cancer can
exacerbate encephalopathy . . . I think the reason we
cannot get her ammonia level down is that the tumor is
growing and there is not much liver left.” Treatment for
ammonia level (lactulose); work up for the extent of the
malignancy was addressed with a chest x-ray, abdominal
ultrasound and a cranial CT, along with multiple discussions
between the attending physicians, radiologists and outside
physicians on how to treat the patient’s likely liver cancer.
Audit finds that the principal diagnosis should be the
hepatic encephalopathy and not the liver cancer with a
decrease in reimbursement.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 12
• MS-DRG 455 was billed with principal
procedure code 81.08 (lumbar fusion,
posterior technique), along with secondary
code 81.06 (lumbar fusion, anterior
technique). Audit finds that documentation
does not support assignment of code 81.06.
Op report documents, “360 fusion L4-4 with
decompression L2-S1.” Only a posterior
incision was made.
• To appeal or not to appeal?
• Lessons learned?
Coding Scenario 13
• Patient is admitted for an ileostomy takedown;
the op report states, “The bowel was divided on
either side of the ostomy . . . then a running
Vicryl was used around to approximate the small
intestine.” Path report stated the small intestine
segment measured 5 cm in length and 2.5 cm in
diameter.” Audit finds that procedure code
45.62, partial resection of small intestine should
not be reported, per AHA Coding Clinic 1991 2Q,
which states minor trimming is included in the
ileostomy takedown code, 46.51.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 14
• Patient presented with choledocholithiasis
with acute pancreatitis, based on CT evidence
and labs; patient underwent ERCP with biliary
stone removal and biliary dilation; discharge
diagnosis is “gallstone pancreatitis”;
choledocholithiasis is reported as the principal
diagnosis. Audit finds that the appropriate
principal diagnosis should be the acute
pancreatitis, 577.0, citing the definition of
principal diagnosis.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 15
• Patient admitted for a chief complaint of SOB and
worsening CKD; discharge summary states,
“Patient with history renal transplant with known
failure due to rejection with increasing fluid
overload and shortness of breath despite OP
attempts at diuresis. Admitted for evaluation and
started on HD.” Original principal diagnosis was
403.91. Audit finds that the principal diagnosis
should be V56.0, admission for renal dialysis.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 16
• The hospital reported a principal diagnosis code
assignment of 404.91, HTN heart and CKD with
heart failure and CKD stage 3 and a secondary
diagnosis code assignment of 486, pneumonia.
The H&P documented “likely” cardiorenal
syndrome (404.91) and leukocytosis “likely due to
prednisone. Cannot exclude pneumonia.” Audit
finds that the principal diagnosis should be
428.33, acute and chronic diastolic heart failure,
and 486 should be removed, per the
documentation that included no discharge
summary or final progress note.
Coding Scenario 16, cont’d
• Documentation review showed that the discharge
summary and final progress note were available
at final coding; no documentation of cardiorenal
syndrome, but discharge diagnosis of acute on
chronic diastolic CHF. Patient does have HTN and
CKD 3; listed as a discharge diagnosis is
“leukocytosis with productive cough and
asymmetrical CSR, treated empirically for
possible pneumonia.”
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 17
• The hospital assigned a principal diagnosis of 996.69,
infection due to device NEC, and secondary diagnosis
code assignment of 998.33, disruption of traumatic
wound injury. Documentation specified an admission
due to wound dehiscence and infection due to the
patient taking sutures out. Audit replaced principal
diagnosis of 873.1, open wound of scalp with
complication and removed code 998.33.
• Documentation shows that the patient did pull his
sutures out, but the sutures were from a surgery one
week prior to this admission where a cranioplasty with
implant was done. For this admission the surgeon
documented that removing the sutures and opening
the scalp exposed the implant, which is now infected
and must be explanted.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 18
• Patient admitted with UTI, has a chronic Foley
catheter due to neurogenic bladder; also has
hemiplegia due to CVA; developed acute
systolic CHF during admission. Audit finds
that there is no clear documentation of the
causal relationship between the UTI and the
catheter, so principal diagnosis code 996.64
was removed and replaced with 599.0 per
AHA Coding Clinic 2012 2Q.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 19
• Patient complains of dyspnea, back pain,
dysuria and fever of 2 days duration; found to
have COPD exacerbation and a UTI; blood
cultures grew E. coli. Discharge diagnoses are
septicemia due to E. coli, COPD exacerbation
and UTI with 491.21 (COPD exac.) assigned as
the principal diagnosis. Audit finds that the
septicemia should be the principal diagnosis
with UTI/COPD secondary as per the Official
Coding Guidelines Chapter 1.
• Appeal or not to appeal?
• Lessons learned?
Coding Scenario 20
• Patient admitted with renal and perinephric
abscess (also has ESRD and uncontrolled DM); the
progress note on day 2 documents, “Sepsis 2/2
pyelonephritis 2/2 staghorn calculi with evidence
of perinephric abscess on CT,” (this same
physician was the discharging physician). Since
the sepsis was not documented on the discharge
summary the coder sent this coding query: “A
localized infection of pyelonephritis is
documented in the patient record. The medical
record reflects ‘Sepsis 2/2 perinephric abscess.’ Is
there also a systemic infection? The blood
cultures were negative?”
Coding Scenario 20, cont’d
• Physician’s answer: “I do believe that this gentleman
had sepsis which is Systemic inflammatory response
syndrome + and infection when he fist presented.
Initially he had tachycardia, tachypnea and fevers
which qualifies as "SIRS". His infection was the
perinephric abscess which required surgery to remove.
He was also quite hypotensive. Over time his " SIRS"
resolved but his infection persisted necessitating a
transfer to OHSU for removal.”
• Audit finds that the principal diagnosis should be
590.2, renal and perinephric abscess, since the
diagnosis of sepsis is not introduced into the record
until five days after admit.
• Appeal or not to appeal?
• Lessons learned?
Thank you!
Carol Kerr, RHIA, CCS
Coding Supervisor
Good Samaritan Regional Medical Center
Corvallis, Oregon
ckerr@samhealth.org