Wiki RAC denial appeal letters

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lcoe0519

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I have a couple of questions. I have been handling denials and writing appeal letters for about a year now. I was sort of thrown into this position. My first question is, can anyone offer me any kind of resources or webinars, online learning opportunities so that I can make better arguments and write better letters? I've done okay so far, but things are getting a little more intense for me and I want to make sure that I'm capable and educated.

My second questions is this, I am currently working on an appeal. The patient suffered a bowel perforation during a colonoscopy. The coder incorrectly assigned the code for a traumatic laceration to the colon as the principal diagnosis, DRG 329. The RAC auditor submitted a denial saying the principal diagnosis should have been K63.1, Perforation of intestine (nontraumatic). While I agree the that traumatic laceration was incorrect, I disagree with K63.1. I believe the correct principal diagnosis should be K91.71, Accidental puncture and laceration of a digestive system organ or structure during a digestive system procedure with K63.1 as a secondary diagnosis. We still lose money on reimbursement, but not as much. So can I write a letter arguing that K91.71 should be principal?
 
Hi
I think ins company is correct...K63.1 because that is what happen. I'd add a dx code K91.71 as 2nd dx code. and one of the T dx blocks. Does the med records state that an misadventure or error was made during the colonoscopy?Check to add the dx blocks of the T codes of T88 or T85 probably help if appropriate. As resources in doing appeals check NCCI, IOM, and CMS Medicare regarding these gastro procedures. Or quote a reference from online medical specialist website.
I hope this helps you.
Lady T
 
I may be way off base here, because this is completely NOT my area, but I thought non-traumatic meant pathological or ideopathic, such as a spontaneous rupture or rupture caused by disease. Wouldn't this be a traumatic laceration/puncture?
 
I think it is technically a traumatic laceration and certainly that is what the original coder was thinking, but I think the ins company feels traumatic meaning external trauma.
 
TThivierge said:
Hi
I think ins company is correct...K63.1 because that is what happen. I'd add a dx code K91.71 as 2nd dx code. and one of the T dx blocks. Does the med records state that an misadventure or error was made during the colonoscopy?Check to add the dx blocks of the T codes of T88 or T85 probably help if appropriate. As resources in doing appeals check NCCI, IOM, and CMS Medicare regarding these gastro procedures. Or quote a reference from online medical specialist website.
I hope this helps you.
Lady T
Click to expand...
Yes the chart says it happened during a colonoscopy which is why the patient was admitted.
 
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