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Denials Are More Complex, Overturn Rate Has Dropped, Experts Say

When an auditor removed a secondary diagnosis of acute and chronic respiratory failure (code J96.21) from a claim for a patient with a history of chronic obstructive pulmonary disease (COPD), the hospital had grounds to appeal. In its denial, the auditor said diagnosing respiratory failure in COPD patients requires a degree of change in their state, not just chronically lower oxygen pressure and increased carbon dioxide. But the auditor was wrong, and the documentation proved it. As the hospital explained in its appeal, when the patient presented to the emergency room in moderate respiratory distress, he had been using three liters of oxygen at night but then required six liters to maintain oxygen saturation of 93%. “The doubling of the patient’s oxygen requirements to maintain an oxygen saturation greater than 90% clearly demonstrates a change from the usual state,” according to the appeal letter, which also noted that a drop in partial pressure of oxygen equal to or greater than 10 to 15 millimeters of Mercury “generally indicates acute respiratory failure.”

The hospital won the appeal, said physician Adriane Martin, vice president of physician services at Enjoin, a clinical documentation improvement company.

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