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Expert Q&A

I have been working on appeals at my facility and have come across this frequently: Payers deny diagnoses based on their own clinical criteria, saying the documentation doesn’t meet their definition. AHA Coding Clinic 4Q 2016 (pp. 147–149) mentions that payers may require specific criteria to establish a diagnosis. Has anyone successfully challenged this or asked Coding Clinic for clarification?

March 27, 2025 · Anna McGraw

Yes, we see this as well. It is a bit sticky, for sure.

Here is ACDIS advice from the 2022 update of their “Guidelines for Achieving a Compliant Query Practice:”

“Clinical Indicator(s)

… While organizations, payers, and other entities may establish guidelines for clinical indicator(s) for a diagnosis, providers make the final determination as to what clinical indicator(s) define a diagnosis.⁴”(emphasis added)

The reference referred to is Coding Clinic 1st quarter, 2014.

We are guessing they are referring to page 16: “Coding Disputes with Payers.”

It states, “Question: Can you help with coding disputes with payers when they don’t follow Coding Clinic advice or the Official Guidelines for Coding and Reporting?

Answer: Traditionally Coding Clinic does not address coding for reimbursement. Coding Clinic’s goal is to provide advice according to the most accurate and correct coding consistent with ICD-10-CM and ICD-10-PCS principles. The official guidelines are part of the HIPAA code set standards. There are a variety of payment policies that may impact coding. Some payment policies may contradict each other or may be inconsistent with coding rules/conventions. Therefore, it is not possible to write coding guidelines that are consistent with all existing payer guidelines. (emphasis added)

The following advice is provided to help providers resolve coding disputes with payers:

  • First, determine whether it is really a coding dispute and not a coverage or payment issue. Therefore, always contact the payer for clarification if the reason for the denial is unclear.
  • If a payer really does have a policy that clearly conflicts with official coding rules or guidelines, every effort should be made to resolve the issue with the payer. Provide applicable coding rule/guideline to payer.
  • If the payer refuses to change its policy, obtain the payer requirements in writing. If the payer refuses to provide their policy in writing, document all discussions with the payer, including dates and the names of individuals involved in the discussion. Confirm the existence of the policy with the payer’s supervisory personnel.
  • Keep a permanent file of the documentation obtained regarding payer coding policies. It may be come in handy in the event of an audit.”

Payers are permitted to make their own rules. But so are hospitals. It might prove helpful to have your own hospital policies and procedures regarding certain clinical criteria to make certain diagnoses – be sure to get physician buy-in and involvement making the polices. You can send the policy along with an appeal that demonstrates how the patient met the hospital’s criteria for the diagnosis.

We also advise to get out of the payer’s internal level of appeal and get your appeal to an external reviewer, if applicable.

The biggest way to make a change, though, is with your contracts.

  • What do your contracts say?
    • If they agree to use the payer’s criteria, you are fighting a very steep and uphill battle.
    • We suggest checking out the contracts and try to get them changed if needed.
      We hope you find this helpful.

Answered by: Karla Hiravi, BSN, RN | Vice President Clinical Resources, AHDAM and PayerWatch

Karla is a registered nurse and holds a BSN from the University of Pittsburgh, Johnstown. She has over thirty years of varied experiences in healthcare, including Clinical Documentation Improvement (CDI), management of a CDI department, development of a hospital-based denial and appeal program, development of an oncology research program, nurse and physician education, appeal writing, presentations at the Administrative Law Judge (ALJ) level, and direct management of appeals at every level, up to post ALJ appeals.

She was a frequent guest speaker at the University of Pittsburgh, Johnstown for many years, and served as a preceptor for nurse practitioner and Pharm D. students while they studied medical research through the University of Pittsburgh. Karla has been with PayerWatch – AppealMasters since 2016 and continues to participate in and educate clinicians and coders about the medical appeal process.

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