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Working Together to Achieve Denial Prevention

Posted By Tiffani Smith, CCS

Coders can all agree that when we receive a denial from a payer, we roll our eyes and cringe a bit.

In place of being proactive, we are now forced in a reactive position to re-review documentation, locate the issue, consider facility-specific and payer-specific guidelines, gather additional documentation and resubmit, hoping that the process will result in appropriate reimbursement. All Facility Revenue Cycle Professionals including CMO’s, CDI and Coders would love to find a way to greatly reduce if not almost eliminate receiving the dreaded denial.

So, how can we accomplish this?

One way would be to target those diagnosis that are likely candidates to be challenged. We all know them, conditions like Sepsis, Anemia, Malnutrition, Hyponatremia, Encephalopathy, Acute Respiratory Failure and the list goes on. I saw that eye roll!

Luckily, some forward-thinking individuals and their facilities have come up with another possible solution.

They are forming Clinical Guideline Committees (CGC). These CGC are the same that may one day lead to a national or even international “handbook” for industry standard clinical indicator guidelines. This collaborative approach would alleviate differences in payer & facility specific, physician and coder/clinical documentation improvement (CDI) guidelines. 

Clinical Guideline Committees (CGC) are typically made up of the following key stakeholders:

  • Payers
  • Facility representatives
  • Billing Coordinators
  • Physicians, Coders
  • CDI professionals

As Karen Elmore, BSN, RN, CCDS, and Samantha Cantin, RN, BSN, CCDS, explained so eloquently during their ACDIS virtual session “Clinical Guidelines: Your Ace in the Hole.” , it is only together that we are able to look at the clinical indicators for frequently denied conditions to formulate and agree upon clinical indicators that are reliable and consistent with the conditions.

The clinical guideline committees may rely on condition specialists for input and suggestions. For example, when discussing Malnutrition, they consult with nutritionist and dietitian professionals using ASPEN (American Society of Parentenal and Enternal Nutrition or KDIGO guidelines for renal conditions. They can also correlate adaptations to software utilizing AI (artificial intelligence) technology to improve physician responses for specificity when a condition is documented. The software companies refer to this as fusion narrative real-time and interactive technology. While technology can be a wonderful tool for efficiency, the physician who observes and is hands on with his patient, always has the final say with the conditions that are diagnosed and treated.

So, what is the hold up?

Perhaps the most difficult hurdle is having all the participating entities agree, implement and utilize the handbook as a uniformed guideline. At the end of the day, we all need to work together to achieve standardization of clinical indicators reflective of the conditions being evaluated, diagnosed and treated. Until then, let’s all dream big to prevent denials.



1: Karen Elmore, RN, BSN, CCDS & Samantha Cantin RN, BSN, CCDS BJC Healthcare Clinical Guidelines: Your Ace in the Hole (ACDIS Virtual)

2: Laurie Prescott RN, MSN, CCDS, CDIP CDI Education Specialist -HCPRO

3: Patrick Dougherty General Manager M-Scribe