Recovery audit contractors (RACs) are not permitted to perform clinical validation reviews anymore, but they’re popular with Medicare Advantage (MA) and commercial payers, which may deny inpatient claims for acute respiratory failure, sepsis and other diagnoses that they say aren’t supported in the medical records. But some payer arguments may not be grounded in clinical evidence or a contract provision or policy, and hospitals have a better shot at changing the payer’s mind about the diagnosis at the time they respond to a documentation request than during a full-on appeal, an attorney said.

A “mini-appeal” is one strategy for dealing with the growth in clinical validation reviews, said Richelle Marting, an attorney and certified coder in Olathe, Kansas, at a Jan. 27 webinar sponsored by the Health Care Compliance Association.^[1] In response to a payer’s documentation request, hospitals would put a single page on top of the medical records that explains how the elements for the diagnosis were met. “It’s a lot easier to stop the appeal on the front end than to appeal the adverse decision,” she said.

For example, payers often target sepsis and other complications or comorbidities (CCs) or major CCs because they fatten MS-DRG reimbursement. When they request the medical records, Marting recommends hospitals also include a cover sheet that highlights how the Sepsis-3 diagnosis criteria were met, including information about the patient’s Sequential Organ Failure Assessment (SOFA) score. “If the chart isn’t strong with Sep-3 criteria, and if the payer requesting records has not formally adopted Sepsis-3 as the only diagnostic criteria they will accept for payment, I may lead with something like, ‘The hospital has adopted criteria for Sep-1 or Sep-2.’” Unless the payer has formalized its use of Sepsis-3 in the contract or a provider manual, the hospital has a strong argument for the physician’s diagnosis with other criteria.