Lately, I’ve been thinking about how to prevent claim denials, especially considering the high number of claims that were denied in 2021. As coders, we can use critical thinking skills to improve the accuracy of our coding and ultimately reduce claim denials. Critical thinking involves formulating questions, gathering information, applying the information, considering the implications, and exploring other points of view.
In coding, critical thinking can be applied by asking questions such as “What is wrong with this patient, and how many resources were used to treat them?” To gather information, it’s important to read and understand the clinical information in the chart and jot down the relevant diagnoses and procedures. Then, codes are assigned, and any information gaps or conflicting information must be addressed.
Considering the implications of the codes assigned is the next step. Does conflicting information impact the MS-DRG or APR-DRG assignment? Does missing information impact the code assignment? Would additional information provide a more specific code? By using critical thinking skills in coding, we can improve accuracy and reduce claim denials.
The final step in critical thinking is to explore the likelihood of claim denial. A complication or comorbidity (CC) or major CC (MCC) can increase the chances of denial, as can conflicting or missing information.
To illustrate this process, let’s consider a patient who presents to the emergency department after a fall and is later diagnosed with a hip fracture. The patient also experiences confusion at times and is dehydrated. The provider documents dementia and toxic metabolic encephalopathy in the progress notes, but the discharge summary does not include the latter diagnosis.
Using critical thinking, we can identify the relevant information and note any conflicting documentation. In this case, the lack of consistent documentation regarding the patient’s confusion is a concern. Additionally, the diagnosis of toxic metabolic encephalopathy is not carried through to the discharge summary, which could lead to claim denial.
Given that toxic metabolic encephalopathy is the only MCC on the chart, there is a high likelihood of claim denial, which could be addressed with a physician query to clarify the diagnosis and close any loose ends.
As coders, we rely on critical thinking skills every day, for every chart we work on. By applying these skills, we can prevent reimbursement loss, delays, and the need to respond to claim denials. In some cases, taking the time to resolve conflicting information can prevent a denial altogether.
It’s crucial to remember to utilize critical thinking skills when coding charts to ensure accuracy and reduce the risk of claim denials.