When Your Payor Disputes Coding Accuracy
Many providers have experienced a significant increase in clinical validation denials, citing a 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,e 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.
Learning Objectives:-
Areas Covered in the Session:-
Background:-
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.
Who will Benefit?