Using the AHA "Coding Clinics" To Deny DRGs

Insurance companies frequently deny medical claims submitted by hospitals. One type of denial payers will use is the "DRG Denial." Here, the insurance company - frequently through a third party service - will go through a chart after the claim has already been paid and deny various diagnoses as "not clinically relevant."

Usually, they will deny those diagnoses that increase the severity of illness, and then they come back to the hospital and claim they have been "overpaid" by thousands of dollars. Other than alleging that a diagnosis is "not clinically relevant," many times the insurance company will cite a "Coding Clinic" article by the American Hospital Association from the 4th Quarter of 2016 and say, "A payer may use a specific set of diagnostic criteria for a diagnosis," or something to that effect, and then go one to deny the presence of that diagnosis.

What?

So, I got a hold of that "Coding Clinics" article from the 4th Quarter of 2016. First of all, the entire document is 150 pages, and they cite one portion of one sentence. Here is what it actually says about who gets to make the diagnosis for the patient (emphasis mine):

Coding must be based on provider documentation. This guideline is not a new concept, although it had not been explicitly included in the official coding guidelines until now. Coding Clinic and the official coding guidelines have always stated that code assignment should be based on provider documentation. As has been repeatedly stated in Coding Clinic over the years, diagnosing a patient’s condition is solely the responsibility of the provider. Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient. As also stated in Coding Clinic in the past, clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgment, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

The article goes even further (emphasis mine again):

While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria.

So, the Coding Clinic article is absolutely clear that the only entity that is allowed to diagnose the patient is the TREATING CLINICIAN. Not the insurance company. Not the third-party auditor. Not AI. I don't understand how they use this article and then justify - with a straight face - denying various primary and secondary diagnoses. It is super annoying, and I just want to make sure people understand how specious the "Coding Clinic" justification truly is.

See the actual page in Coding Clinics article:

Watch my conversation with Dr. Vivek Tirmal about this issue: