Top Tips for Successful Clinical Validation Appeal Arguments

By Breen Nabors, RN, CCDS | March 30, 2021 

The dreaded denial letter comes across your desk disputing a major diagnosis that undoubtedly will impact your facilities reimbursement. Try not to fret. Think of it as a second chance! It may not be often that you get to set aside a piece of your day for one diagnosis in a medical record. If you write denial letters full time you may do this often, however, if you code medical records, send queries, or round with providers then you know that spending an hour on one diagnosis does not happen often. Use the proverbial fine tooth comb to get every piece of supporting evidence. Now is the chance to prove the diagnosis in question is supported and definitely should be captured on the final coding summary. In this article you will learn tips for writing a successful clinical validation appeal letter. Since sepsis is always a topic of discussion, this diagnosis will be used for an example.

  • Be sure to point out every time the diagnosis in question is documented. Consistency is key. The more the diagnosis is stated, the better your letter will appear. Obviously, capture the attending documenting the diagnosis but do not leave out everyone else! Don’t forget to reference the specialists weighing in their opinion. The admission order is a great place to find the diagnosis of sepsis. Sepsis is often the indication for antibiotics. Some facilities have sepsis scores performed by nurses, which are included in the medical record. The bottom line, leave no stone unturned. Even if the diagnosis is not consistently documented, the supporting documentation below can help support the diagnosis.
  • Remember all the signs and symptoms. Try to remember the person reading your letter is not at the bedside looking at the patient. Now is the time to paint the picture of how sick this patient really was. Add all the documentation that described the patient, chronically ill, fatigued, lethargic, distressed, or weak. If the patient had sepsis, they most likely will appear this way and it is important for the reader to know that.
  • Do not miss any abnormal lab values. It is important to show consistent abnormal lab values. Most diagnoses of sepsis are not derived from one abnormal white count. If you have them, flaunt them. Prove that the leukocytosis continued on for several days despite antibiotic treatment. Document the elevated lactic acid levels and how they may have trended down with fluid resuscitation and antibiotics. It can also be a good idea to document trends, since monitoring is a crucial factor in Coding Rules and Guidelines. Displaying the values in a chart can be impactful.
  • Do not miss any abnormal vital signs. It sounds redundant but this is crucial. It has been documented many times on letters from payers one set of abnormal vital signs. Now is your time to prove how sick the patient really was. Capture all of those elevated respiratory rates, every elevated temperature, every elevated heart rate, or oxygen desaturation. Despite what the letter says, once you take a close look you may find the abnormal vital signs continued after the patient was admitted. Just like the lab values, show the patient had these consistent indicators of the diagnosis in question. Trends back to normal are not always necessary in this situation since you want to hone in on abnormal findings.
  • Point out every criteria that is met. Providers are not bound to certain diagnostic criteria. If the patient met criteria that your facility uses, point it out. Often time’s payers will mention one criteria in the denial letter, for example Sepsis 2 criteria. If the patient also meets SOFA criteria, explain how the patient met this criteria as well. Acknowledging that multiple criteria were met could prevent future denials.
  • Dispute the denial letter. If the denial letter states the patient had no signs or symptoms of the diagnosis and you know they did, point it out. Explain, again, all of the signs and symptoms. This causes the reader to take yet another look. Denial letters often times write the documentation was only documented in the H&P even though it is stated in every progress note and on the discharge summary. Be sure to stand up for the providers who took the time to document appropriately and consistently in the medical record. Do not be afraid to say The denial letter incorrectly claimed
  • Keep medical literature updated and readily available. Denial letters often state egregious statements like the patient had no positive blood cultures. We all know that a patient can definitely have a diagnosis of sepsis without positive blood cultures. Explain this in your letter but it is always nice to have the science behind your argument. Be sure to reference medical literature from journals, articles, coding clinics, or coding guidelines. These extra tools can show that you have gone above and beyond to find supporting arguments for the diagnosis in question.

If you follow these tips, you are sure to write a successful clinical validation appeal.

About the Author:

Breen Nabors, RN, CCDS | Clinical Audit and Appeal Services

Intersect Healthcare + AppealMasters

Breen Nabors RN, CCDS is a clinical appeals consultant for Intersect Healthcare + AppealMasters. She has been in healthcare for fifteen years. The foundation of her nursing includes the trauma intensive care unit and surgical services. She worked in clinical documentation for three years prior starting in denials and appeals management. Breen currently writes a variety of appeals with clinical validation being her forte.

Contact the author:

bnabors@intersecthealthcare.com