Wiki Coding review/Med Management review do not agree

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rdarla

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I work for a payer and do Post Payment Review on inpatient medical records. A frequent case scenerio envolves coding review finds the facilities coding substantiated per the documentation in the chart notes and according to ICD-9-CM guidelines. Review by Medical Management finds that clinical criteria supporting a diagnosis (usually the principal diagnosis) has not been met. Coding feels pressured to change their review to reflect Medical Managements determination. I would be interested to know if others who work for payers experience this problem and if you have a solution for resolution.
 
Most of us will need a little bit more detail. Who are the people in "Med Management?" What are their credentials and their role in the organization?
 
Medical Management is a team of physicians (Medical Directors) who do post payment review on institutional claims for determination of over-payment. Often, they will find a diagnosis not clinically substantiated in the record although from the coders perspective it is documented. The claim is denied per the physicians decision. The claim is appealed by the provider and comes back to the coders for review and the diagnosis is found substantiated per the documentation. The physicians disagree. We go back and forth with this until all levels of appeal have been exhausted. The coders explain the coding guidelines but, the physicians just do not accept them.
 
I think I understand what you are saying but can you give a specific example? the documentation , the coders dx and the mgt team's perspective?
 
A common example is sepsis. The coder's see sepsis documented and present on admission in the medical record. The physicians (Medical Directors) say the clinical criteria for the diagnosis of sepsis is not met. The physicians have the final decision and the claim is denied. The provider appeals. The claim comes back to the coders to review if sepsis is substantiated. Of course, per the documentation, it is. The physicians again say the clinical criteria for the sepsis diagnosis is not met. The coders are pressured to agree with the physicians, but, of course we can't just say we don't see sepsis POA not documented when it clearly is.
Another example is diabetes and the proper sequencing according to the etiology/manifestation guidelines concerning diabetes. Take gastroparesis for example. There is clear cause and effect documented in the medical record. The physicians (Medical Directors) say gastropareis is the principal diagnosis and diabetes secondary diagnosis. We explain and even show the etiology/manifestation guideline to the physicians and they just refuse to accept it. They have final determination and the claim is denied.
We have first-level appeal, second-level appeal and committee level of appeal. These two diagnoses unnecessarily usually make it all the way to committee level of appeal. A committee level of appeal is usually made up of managers (director level) and physicians. It is not unusual for it to take a claim two years to make it through all the levels of appeal.
It is very frustrating to have this scenerio played out over and over again.
 
Well, your physician directors lack the proper training to fulfill their roles, it sounds like. Since the coders are not making medical review decisions, the providers should be kept from making coding review decisions. Too, at some point your employer needs to determine itself with properly educating these physicians.

In the event that this relates to a government contract, I would be very concerned since it is likely a breach of contract provisions--though I am speculating.
 
I agree with Kevin, A coder cannot second guess the providers' documentation and diagnostic determinations, we only code what is there using the guidelines to assist. I have had other coders even state that if the conditions for sepsis are not documented then don't code sepsis, and it is not so. If the provider states sepsis then it is and the guidelines tell us to use 038.9 first listed if no other organism is documented. I have run headlong into the diabetes issue as well. The rationale I use on this one is we need to use first-listed the reason the patient is here, they were not here for gastroparesis, they were here for a complication of the diabetes which is why that code must be first listed, we use the manifestation secondary to be more specific as to the complication.
My point is sometimes you need to reword your argument to be something more logical in their eyes. Always keep the patient as the most important issue and explain that it is the patient's dx you are communicating to the payer. Hopefully ICD-10 CM will fix some this as the codes are much better.
 
Thank you both for your replies and input. Our department is restructuring and our new manager supports separating coding reviews from medical management reviews. Our old system wanted the coders and physicians to agree. It didn't work and I think when we do our independent coding reviews things are going to be much better. :)
 
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