Q&A: Code removal requests from payers

Q: How do you handle clinical validation denials when payers say you won’t receive payment unless you remove a code from the claim? If the hospital removes the code, which is well-documented in the chart by the provider, is this a compliance issue? In these instances, the coding team does query to validate prior to billing, but the providers often stand by their professional opinion. As a result, the code goes out on the claim. How does this impact quality outcomes/rankings, denials, payments, etc.?

A: Appeal—and fight like heck! Payers should not be able to make up their own definitions of diseases. Now, if a patient is on 2 liters of oxygen, and the doctor writes “acute respiratory failure,” then you don’t fight.

Be sure your finance team knows about these [denials] and get the contract changed to forbid payers from using their own definitions.

If a Medicare Advantage plan denies a diagnosis, ask them if they are also withdrawing the corresponding hierarchical condition category from your Medicare reports. To not do so would be fraud.

Editor’s note: This question was answered by NAHRI Advisory Board member Ronald Hirsch, MD, FACP, ACPA-C, CHRI, CHCQM-PHYADV, vice president of the regulations and education group at R1 RCM Inc. Physician Advisory Solutions in Murray, Utah on the NAHRI Forums.