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Are coding denials by insurers such as Humana, Aetna, Blue Cross now taking over your time or the time of your denials management staff?

Clinical validation denials are now widespread and intrusive. Many of the targeted diagnoses have been documented clearly and consistently in the medical record but do not meet accepted published clinical indicators.

Official coding advice directs coders to code diagnoses that are documented by a physician as long as there is no conflicting documentation. Is the fact that the clinical “information” contained in the record does not “confirm” the diagnoses documented by the provider enough to remove the code(s) from the claim and pay the claim under a different DRG?

We have reviewed and appealed hundreds of such denials. We will share with clinical documentation improvement team the diagnoses receiving the most denials and clinical criteria used to make the denial. We will share our findings, successful appeals and those that were unsuccessful and why.

Concurrent clinical validation of the principal diagnosis, and CC/MCCs which determine the MS-DRG by CDI is necessary to ensure the documentation in the medical record supports the codes assigned thereby preventing future clinical validation denials. Learn how to compose physician queries that will obtain the clinical indicators to support or rule out a diagnosis that is not appropriate.


Ms. Barbara Flynn, RHIA, CCS is the Vice President of Code & Comply Specialists a nation-wide HIM consulting and compliance consulting firm offering clinical coding services, coding compliance and documentation audits, CDI education and HIM management. Code & Comply Specialists is a subsidiary of the FHA Management Corporation and has been providing these services for over 25 years. Barbara has been an AHIMA-approved ICD-10-CM/PCS trainer and Ambassador and is widely recognized as a coding and compliance expert. Barbara has provided numerous seminars for FHIMA and other organizations on coding and billing compliance, ICD-10 implementation strategies, appropriate physician queries, regulatory compliance and many other topics over her 40+ year career in HIM.

Ms. Silvia G. Ortiz, MSHSA, RHIT, CMPSM, is a Senior HIM Consultant/Coding QA Auditor for Code & Comply Specialists with over 35 years of experience in the Health Information and Medical Staff Management fields with extensive knowledge in ICD-10-CM/PCS clinical coding compliance, auditing and appeals management. Ms. Ortiz is an AHIMA-Approved ICD-10 CM/PCS Trainer and holds a Master’s degree in Health Services Administration. She is currently a member of AHIMA, FHIMA, and NAMSS and serves on the Keiser University’s Health Information Management Program Advisory Board.


1.0 – Clinical Data Management

Date Published

March 14, 2018