Denial From Medicare Secondary Carrier Regarding Metabolic Encephalopathy

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Case Example:

Denial From Medicare Secondary Carrier Regarding Metabolic Encephalopathy:
The Pt's Record: The physician stated several times that metabolic encephalopathy was secondary to patient’s UTI in the patient record. Every progress note for his 6 days states metabolic encephalopathy was either improving or resolved. Metabolic encephalopathy was NOT used interchangeably with the term "confusion" within this record.
Denial Letter #1: Metabolic encephalopathy as a secondary diagnosis. Pt had UTI, metabolic encephalopathy, and confusion.
Appeal #1: Metabolic encephalopathy is not an integral component of a UTI.
Denial Letter #2: The patient’s metabolic encephalopathy was related and inherent to the UTI based on discharge summary that states: “During this time he was encephalopathy and confused but with the treatment of the urinary tract infection he regained his baseline function and was cognitively intact.”

The denial letter also presented another twist to the denial: The reviewer concluded that because the H&P stated "confusion/encephalopathy" and the D/C summary stated the above that the two notations are considered to be "conflicting and ambiguous information."

Appeal #2: Metabolic encephalopathy meets guidelines for secondary diagnosis and reiterates the information is not conflicting/contrasting information within the record.
CDI Advice:
In this case, I would cite Coding Clinics and coding guidelines to defend the secondary diagnosis … (And some general medical knowledge! They should be glad you didn’t try to make a case for sepsis … maybe this one could have really been SIRS 2/2 UTI with metabolic enceph … then the payer would have to pay even more! Who admits a patient with just a UTI anymore?)

  1. 348.31 metabolic enceph can be a standalone diagnosis. It is ALWAYS DUE TO SOMETHING ELSE (just like respiratory failure …) Coding Clinic Fourth Quarter 2003: “Metabolic Encephalopathy: is always due to an underlying condition. There are many causes of metabolic encephalopathy, such as brain tumors, brain metastasis, cerebral infarction or hemorrhage… Metabolic Enceph. may be the first manifestation of a critical systemic illness and may be caused by various reasons—one of the most important being sepsis.”

  1. The above Coding Clinic designated metabolic enceph as a separate condition that should not be defined as delirium or acute confusional state … The Coding Clinic supersedes the older Coding Clinic related to metabolic enceph (delirium), First Quarter 1988, which stated that “metabolic enceph refers to an altered state of consciousness, usually denoting delirium … the term acute confusional state may be used by some physicians to describe metabolic encephalopathy … the code assignments in the Alphabetic Index of ICD-9-CM for delirium and acute confusional state are compatible.”

  1. Confusion IS A SYMPTOM OF METABOLIC ENCEPHALOPATHY … Also, this case seemed to be “septic enceph” (which codes to the exact same thing as metabolic enceph) and is defined as “altered brain function owing to the presence of infectious agents in the blood, including the effects of fever, symptoms vary from mild to severe and may include CONFUSION, myopathy with rigidity, and more serious condition such as seizure or coma” (Dorland’s Medical Dictionary). I would query the MD to get documentation that the “confusion” was one of the symptoms of the pt’s enceph (and include any other hallmark symptoms of enceph that were documented).

  2. Your MD defined the treatment for enceph, which was treating the UTI … So both were treated! Enceph does meet the definition for a secondary diagnosis. Enceph is not a symptom that is routinely associated with a UTI. (Not everyone that has a UTI has confusion NOR enceph. We don't know of a rule with enceph that states “code first,” “use additional code,” or “in disease classified elsewhere” so I think they missed the mark saying that you shouldn’t be able to claim enceph as a secondary dx.

Case Example:

Internal Audit Case Review for Sepsis DRGs
Case Review Type: Sepsis as a principal diagnosis for short stay patients

The Pt's Record:

60 y/o male patient admitted with non-healing lower extremity surgical wound. Non-healing infected wound well documented as reason for admission by the hospitalist. No SIRS indicators POA. 2 day LOS. Wounds cultured, antibiotics given. HD #1, physician assistant documents “Sepsis RLE with culture spec 4+ GPC on Gram stain” and “Non-healing wound RLE.” A different hospitalist writes discharge summary and documents infected wound as discharge diagnosis—no mention of sepsis anywhere in chart. Coder queries post-discharge for sepsis POA. D/C hospitalist’s query answer “Sepsis was POA.” Sepsis is coded as principal diagnosis.

MD Review: 2 physician reviewers both state sepsis cannot be clinically validated based on the record.

What to do: Should this case be corrected and re-billed as a lower DRG?

My Advice:

I write appeal letters frequently for RAC and commercial denials, so this is what I would do in this situation. Ask the MD to addendum the discharge summary to include sepsis, POA status, and reflect the clinical indicators that validate the patient had sepsis (especially those that were present on admit.) I would also ask the MD to reference any documentation from the record that substantiates previous outpatient treatments, failed antibiotics, cultures, etc., that were tried prior to the patient being admitted to the hospital. This documentation can help validate a diagnosis of sepsis (SIRS due to infection). Truly, it is the MD that has the ability to “diagnose” a condition based on his/her clinical opinion. With that said, the MD will have to support the diagnosis by documenting clinical indicators, treatments, plans, and concerns. If the patient didn’t meet SIRS criteria on admission, the MD should be able to defend “sepsis” with the other indicators that lead to the diagnosis of sepsis.

Case Example:

Secret Agent and Detective: Denial for ARF
The Pt's Record: ARF clearly documented throughout the record.
The Denial Letter:
"Their contention is that the documentation does not support reporting, for billing purposes, a diagnosis of renal failure. The coded official coding guidelines that state ‘A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.’
“Further stated while it is not the coder’s responsibility to question a physician’s clinical judgment, it is the coder’s responsibility to validate diagnosis and/or procedure codes submitted for reimbursement purposes. While a condition may consistently be documented, it is the responsibility of the coder to ensure that all assigned codes are supported by clinical evidence that the condition exists and is supported prior to code assignment. A coding validation specialist must determine the following 1) whether the diagnoses/procedures submitted on the claim are documented clearly and consistently in the medical record by the provider and 2) whether the diagnosis/procedures submitted are appropriate for inclusion in the claim.”
They referenced a Med Learn Matters issued by CMS March 2011. “As with all codes, clinical evidence should be present in the medical record to support code assignment.”

Secret agents must also "police" the record:
It is not enough for the MD to just note a diagnosis every day! The chart must substantiate the diagnosis, itemize the treatments, and reflect the outcomes completely in order for payers to validate a diagnosis.

Case Example:

Herding Cats ... Query
Documentation clarification [date, time], Visit: 123456789, complete, revised, signed in full, priority, general
Documentation clarification:

Please exercise your independent, professional judgment when responding. A specific answer is not anticipated or expected.

In your clinical opinion:

Dr. X,
Progress notes from 1/17 and 1/18 state pt had "ARF-suspect contrast nephropathy." This condition was not listed in the discharge summary. In order to code this chart correctly, further clarification is needed.
1) Do you still agree this condition was present, suspected, or was it ruled out by discharge?
2) Can you also further clarify "ARF-suspect contrast nephropathy" (contrast nephropathy is an unspecified term/phrase) as:

  • ARF secondary to ATN from contrast media

  • ARF unspecified

  • Cannot further specify/determine cause of ARF

  • Other (please specify condition): ___________________

**Please note the answers for the 2 questions. Feel free to call me prior to answering this query if you have questions.

Thank you,
CDS name

Contact info

 MD response

Pt. did have some ARF - likely due to contrast induced nephropathy but improved w/ some IV fluids.

Electronic signatures:

Clinical documentation specialists (signed, date, and time)

Authored: Documentation clarification

Dr. X (MD) (signed, date, and time)

Case Example:

Query #1 for Condition, MD Education Needed
Documentation clarification [date and time], Visit: 987654321, complete, revised, signed in full, general
Documentation clarification:

- Please exercise your independent, professional judgment when responding. A specific answer is not anticipated or expected.

 In your clinical opinion:

Noted in PNs 1/15 and 1/16 "positive use of accessory muscles" and "acute on chronic respiratory failure." Per ED RN "using some accessory muscles to breathe (abdominal) with slight suprasternal retractions."
Can you please clarify if acute on chronic respiratory failure is:



--ruled out

--unable to determine

***To answer: open document, select "modify" at the top, answer in bottom box, then select "save" at the bottom. Please answer and carry answer/dx forward into future PNs and DC summary***

Please call with questions.

Thank you,

Documentation specialist

Contact info

 MD response

He has an acute exacerbation of COPD. He still has wheezing as documented in my note.
Electronic signatures:

Dr. D (signed, date, time)
Clinical documentation spec (signed, date, time)

Authored: Documentation clarification

Case Example:

Query #2 for Condition, MD Education Provided

Documentation clarification [date and time], Visit: 987654321, complete, revised, signed in full, priority, general
Documentation clarification:

 In your clinical opinion:

Dr. D,
Thank you very much for taking time to answer the last query regarding "acute on chronic respiratory failure," a diagnosis that was previously been documented in the progress notes by Dr. W on 1/15 and 1/16. Your answer noted that "He has an acute exacerbation of COPD. He still has wheezing as documented in my note."
Dr. Wr diagnosed acute on chronic respiratory failure and added it to the patient's problem list in her records. Your subsequent progress notes did not reflect notations related to acute on chronic respiratory failure or the status of the condition as resolved, ruled out, etc.
Coding guidelines require further clarification to determine if pt had "acute on chronic respiratory failure." (This condition is considered a separate diagnosis from exacerbation of COPD with wheezing; for example, COPD exacerbation could be the underlying condition that caused acute on chronic respiratory failure, and wheezing could be the continued symptoms of the underlying condition.)
As the current attending, respectfully, I need to ask you to clarify if you agree with the diagnosis of "acute on chronic respiratory failure." Please note your clinical opinion. If you agree that this condition was present, please update the patient's problem list. If you do not agree, please not your opinion below. If the condition was ruled out or resolved, you may also further note the status of this condition. (example: acute respiratory failure is now resolved)

Do you agree with Dr. W in regards to the diagnosis of acute on chronic respiratory failure?

Please call me if you need any additional information or clarification from me related to this clarification. Thank you for your time.

Thank you,


Contact info

 MD response

Yes he had acute on chronic resp failure. Yes it is getting better as of yesterday.
Electronic signatures:

Dr. D (signed, date, time)
Clinical documentation specialist (signed, date, time)

Authored: Documentation clarification

Case Example:

UM CDS Review Impact RW, GLOS, SOI, ROM, and Cost Outlier Status

Original DRG and Coding Summary

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