Q&A: Consider every claim a story

Q: We recently had a patient with a long-term hospitalization who subsequently died. Her hospital stay was over several weeks. Her diagnoses were long-term diabetes mellitus, chronic obstructive pulmonary disease, plus renal failure, a cerebrovascular accident, and, ultimately, a catastrophic myocardial infarct. Specialists were called in to follow her CVA, renal failure, and pulmonary process. When we billed our services to Medicare, the number of days were denied with the rejection that the diagnoses did not support the level of care. We billed for the things we were following the patient for (diabetes mellitus and COPD). Any suggestions on how we might get similar claims paid without having to send the claim back for appeal?

A: If you consider every claim a "story," you need to give the insurer as much of that story as possible to make sure your claim goes through the first time around. In this way, you will avoid having the claim sent back and the subsequent appeals process.

You likely didn't include the other diagnoses the patient was being treated for in the claim. If that's the case, the "story" the insurer is receiving is that you provided extended inpatient care for diagnoses that affect many people. Even though your colleagues will bill for their services using the diagnoses they are following the patient for, you may do so as well. Do not use secondary diagnoses as the primary diagnoses. Your primary diagnoses should be the diabetes mellitus and COPD (be sure to code them with specificity). The secondary diagnoses on your claims would be the renal failure, CVA, and MI.

The author, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant and is also a certified coding specialist, certified compliance officer, and a certified medical assistant.