ACDIS



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.”

2) 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.”

3) 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).

4) 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

[pic] 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:

1. ARF secondary to ATN from contrast media

2. ARF unspecified

3. Cannot further specify/determine cause of ARF

4. 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

[pic] 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:

--resolved

--active

--ruled out

--unable to determine

--other

***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

[pic] 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,

CDS

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

[pic] Original DRG and Coding Summary [pic]

[pic] Reviewed and Revised DRG and Coding Summary[pic]

Queries Entered After CDS Review:

[pic]

[pic]

[pic]

Queries Entered After CDS Review (cont.):

[pic]

[pic]

BEFORE CDS Review:

[pic]

After CDS Review and Queries:

[pic]

Improvements for Cost Outlier Patient With LOS 21 Days:

Changes removed patient from cost outlier status

RW: Increase from 1.4863 to 2.1479 = 0.6615

GLOS: Increase from 4.6 to 6.3 = 1.7

SOI: Increase from 3 to 4

ROM: Increase from 3 to 4

Case Example:

Readmission Appeal Letter for Medicare Advantage Plan

Any Date, 2012

To: Insurance Provider

Re: Patient Name: Mrs. X

Subscriber #:

Provider #:

Dates of Service: 10/30/-11/29/

Claim/Audit #:

Dear Medical Claims Review Department:

After review of your denial letter for the above dates of service, we are formally appealing this denial and request for you to overturn your denial decision. We feel that this patient was stable for discharge on 10/29 and will prove that the patient’s readmission on 10/30 could not have been potentially preventable. The clinical presentation of this patient, along with documentation previously and additionally provided, and this explanation will illustrate proof that the patient’s readmission was not a potentially preventable readmission.

After a clinical review of the first admission, dates of service 10/17–10/29, and the readmission, we determined that the patient was stable for discharge and the readmission was not based on worsening weakness. The patient was admitted 10/17 for profound hypokalemia with acute on chronic renal failure, hydronephrosis, cellulitis, and had a urethral stent placed. Pt also had malignant hypertension, right upper extremity cellulitis, and dysphagia. At discharge on 10/29, patient’s vital signs were noted as temperature 95.8, heart rate of 59, respirations of 20, and blood pressure of 151/71, oxygen saturation was 94% on room air. Patient did not exhibit any signs and symptoms of shortness of breath, fever, nor urinary tract infection. According to rehabilitation notes, patient showed good effort and was independent with supine to sit and sit to supine. Patient was noted to “ambulate 220 feet using the IV pole for assistance with both upper extremities. IV pole acted in place of rolling walker for this patient. Patient demonstrated better balance with less anterior leaning and decreased cadence today. Patient required cues for heel strike B secondary to wanting to come down on her forefeet.” Labs prior to discharge: creatinine 2.24 (baseline was noted to be 2.0–2.2), potassium 3.8, hemoglobin 9.1, white blood cell count 4.6. Dr. Attending's discharge summary on 10/29 noted patient “feels ‘much better’ overall since admission … No specific complaints, wants to go home.” Review of systems at time of discharge noted a normal systems assessment with stable vital signs. Physical exam noted no accessory muscle use, clear breath sounds, normal respiratory effort, bibasilar crackles, no genitourinary symptoms noted, patient was alert and oriented x4. Patient was then discharged home with family and set up for home health (which was the recommended level of care) follow-up.

Patient’s readmission 10/30, Dr. ER noted that pt was admitted with weakness and confusion. Chief complaint was “patient keeps falling asleep.” Patient noted to have generalized weakness, confused, and combative. Patient was noted to be “unsteady, weak, and requiring 2 people assist.” Final diagnosis for the emergency room portion of the record by Dr. ER was “weakness, altered mental status, and cellulitis.” Emergency medical service record from County EMS noted chief complaint was “confusion and sleeping a lot, daughter noted patient was hard to awaken.” On EMS arrival, patient’s oxygen saturation was 89% on room air. Oxygen saturation increased to 95% on 2 liters per minute nasal cannula. Dr. Attending's history and physical noted “The patient was discharged home yesterday. She was actually stable for discharge. She was evaluated by physical therapy. They recommended home physical therapy and home health. She had been walking around the medical floor and was doing quite well. The family brought her home. She had supper yesterday, walked up the stairs to her room. This morning she was lethargic and weak but she was able to shower by herself this morning, ate breakfast and then after that the family says she was just very lethargic and very weak, so they brought her here for further evaluation. In the emergency room, it does appear she has a severe urinary tract infection with greater than 30 white blood cells and yeast present.” Review of systems generalized fatigue and weakness noted. No dysuria was noted, however patient stated she had some blood in her urine since the stent and she did have urgency. She was noted to have generalized weakness and some mild back pain at times. Emergency Room nursing notes patient admitted with confusion—alert and oriented to self and place but not to time. Vital signs on re-admit per ED nursing notes: temperature 96, heart rate 59, respiratory rate 20 blood pressure 175/76, oxygen saturation was 88% on room air. Lab workup on readmit: white blood cells count was 6.9, potassium was 3.6, creatinine 2.37, hemoglobin 9.6, urinalysis noted as above. Pt was admitted for suspected urinary tract infection and started on IV antibiotics. Urine cultures 10/30 and 10/31 were noted as likely contaminate.

Dr. Attending noted patient’s lungs were “clear to auscultation bilaterally without crackles, rales, rhonchi, or wheezing, normal to percussion.” Dr. Attending also noted “generalized weakness, likely secondary to urinary tract infection. There could be some reconditioning from prolonged hospitalization; however she was evaluated by physical therapy who recommended home health and home health physical therapy. However, due to this admission, she may benefit from a rehab admission for a short stay after the clearing of her urinary tract infection she remains with generalized weakness.” 11/16 urine cultures came back positive for Pseudomonas aeruginosa and patient was started on IV antibiotics. Dr. ID was consulted for infectious disease, determination was made that positive cultures were not a true infection and likely represented colonization since patient has had a prolonged foley catheter. “Antibiotics were discontinued and patient did well and did not decompensate. Therefore, it was felt that patient did not have any underlying infections.” Urinary tract infection was listed “not true urinary tract infection.” Patient’s chest x-ray on admission noted pulmonary congestion. Patient was not noted to have a history of valvular heart disease, congestive heart failure, nor fluid overload. Patient was placed on 2 liters per minute of oxygen in the emergency room for oxygen saturation of 88%. Patient’s oxygen level continued to decline over night of 10/31 and patient was placed on 50% venti-mask on 11/1. Arterial blood gas was 7.34-52-84 on 50% venti-mask. Patient was treated with multiple doses of high dose Lasix IV, but continued to decline and had worsening hypoxia. 11/5 patient had hypercarbic/hypoxic respiratory failure and was intubated.

Dr. Critical Care Intensivist/Pulmonologist noted that since the bilateral opacities were improved after intubation (and given IV Lasix), he believed respiratory failure was related to fluid/pulmonary edema likely related to kidney dysfunction and cardiac disease. Echo revealed moderate to severe mitral regurgitation with diastolic dysfunction. Altered mental status/delirium was attributed to “likely worsening hypoxia, hypercarbia, and respiratory failure. Dr. Cardiologist was consulted for heart failure. Dr. Nephrologist was consulted for worsening pulmonary edema in the setting of chronic kidney disease. He noted that patient has acute diastolic heart failure. Respiratory failure noted to have unclear etiology, but most likely pulmonary edema with diastolic dysfunction and severe mitral regurgitation. Patient’s respiratory status continued to decompensate despite high doses of IV Lasix, IV steroids, and IV antibiotics. Rapid response was called on 11/2 and converted to Bi-pap, and ultimately intubated. Patient developed further decompensation with acute renal failure and oliguria after respiratory status stabilized on ventilator. Patient’s creatinine increased to 6.65 on 11/11 and was ultimately started on hemodialysis.

This appeal comes in light of the entire clinical picture, after study, acute respiratory failure in the setting of chronic kidney disease and diastolic dysfunction with mitral regurgitation—diagnosed this admission—was chiefly responsible for this admission. Patient’s lethargy, confusion, and increased weakness were a change in status after discharge and were related to patient’s impending respiratory failure. In this case, readmission was neither preventable nor avoidable given that patient had not had previous issues with new pulmonary edema, no documented history of diastolic dysfunction, nor noted severe mitral regurgitation. Renal function was near baseline at previous discharge and progressively worsened after respiratory failure and diuresis. Please review this comprehensive review and appeal to overturn the denial decision for this stay. Please feel free to call if you have questions or need additional information. Please also refer to previously submitted medical records along with the additional medical documents provided.

Thank you,

Clinical Documentation Specialist

County Medical Center

(123) 456-7890 office

Enclosures (multi)

cc:

PFS Director

HIM Director

Denial Coordinator

Case Example:

Appeal for Partial Stay and Procedure Coverage (Med Nec)

Date: Any Date, 2012

To: Insurance Provider

Re: Patient Name: Mr. Y

Reference #:

Provider #:

Dates of Service: 12/5-12/09

Claim/Audit #:

Dear Medical Claims Review Department:

We received the denial for inpatient coverage for dates of service 12/07–12/08 based on your claim that “hospital care was not medically necessary” for Mr. Y for those dates. We are appealing on behalf of our valued patient and feel that his hospital care was indisputably medically necessary. This appeal letter will provide supportive evidence that the “test to outline the blood vessels in your [Mr. Y’s] head” was pertinent to determine the underlying cause of the acute left non-hemorrhagic PCA territory cerebrovascular accident in order to establish an appropriate treatment regimen for the patient.

During his stay, Mr. Y was a 54-year-old gentleman that had no significant medical history prior to admission. He works at a funeral home burning dead bodies, which requires heavy lifting. Per the history and physical, he woke up and kept asking the same questions over and over again and was brought to the ED with slurred speech. He was also dizzy and confused at the time. MRI revealed a left PCA distribution infarct. He denied neck trauma or being dehydrated at the time. Carotid ultrasound was performed to evaluate his neck vessels and there was concern for the left vertebral occlusion versus hypoplasia per the neurology consult. The review of systems noted that Mr. Y had difficulty thinking, mild dizziness, but no double vision and headache. He was alert, knew the current date and president, however, he had some difficulty telling the neurologist his date of birth. He was also noted to have decreased fluency in his language. He was also noted to have delayed recall and was zero of three for recollection in this category. The carotid ultrasound noted “there is antegrade flow in both vertebrals but only trace flow is seen superiorly on the left which suggest the left vertebral is hypolastic or partially occluded.” The neurologist also noted that on the patient’s MRI of his brain, “he has a huge area of cytoxic edema on DWI involving medial temporal cortex as well as big part of occipital lobe involving primary visual cortex as well as interior aspect of the occipital lobe. This is whole posterior cerebral artery territory. He does not have other significant white matter microvascular ischemic changes or evidence of further previous infarcts.” The neurologist recommend CT angiogram to make sure that the patient did not have a dissection which was “low likelihood but patient is a heavy worker.” He also noted the patient had “partial occlusion versus hypoplasia of the left vertebral artery.” The neurologist noted “I believe his right homonemous hemianopsia should improve but till that time I am hesitant to give him driving privileges as he has significant anosognosia of his visual deficit and he might be a high risk for accident.” He was noted to also have a headache in which NSAIDs were ordered to treat his headaches. Progress notes by neurology noted that “Acute onset of confusion, amnesia, and right homonymous hemianopsia with left PCA entire territory infarct had significantly improved for the size of the infarct. However, the mechanism of the stroke had not been determined. The patient continued to have memory issues, headaches, and right visual field loss.” Given CTA results that were inconclusive to determine the underlying cause of the PCA and the patient’s continued symptoms, a vascular surgery consult was ordered. The vascular surgeon noted that “Left vertebral stenosis/hypoplasia given the inconclusive result of the CT and ultrasound, I recommend that he have an angiogram and possible intervention.” The patient was kept NPO overnight and taken to the operating room the next day for an arterial aortogram and selective injection of the left vertebral artery. Per the operative report, Indications for the procedure were: “the duplex ultrasound as well as the CT angiography demonstrates possible vertebral artery stenosis with poor flow. They are inconclusive and therefore the angiography is being performed WITH THE HOPE OF INTERVENTION.” The report noted that “magnified views demonstrate the vertebral artery is occluded. The H1 catheter was then removed.” “The stump of the vertebral artery is noted. It is engaged with the H1 catheter and hand injection of contrast with magnified views utilized to focus on this area. There is no string sign. There is occlusion of the vertebral artery approximately 8 to 10 millimeters from its origin. No further treatment was warranted” surgically at that time.

Based on the type of stroke the patient had and his continued signs and symptoms, the medical team felt that it was imperative to follow up on the inconclusive findings by performing the angiogram with the hope for possible intervention. Best practice standards in the neurological community have mandated that treatment and prevention of further PCAs are dependent on determining the underlying cause/mechanism of stroke involving the PCA territory. Per Posterior Cerebral Artery Stroke¹, authored by Dr. Erek Helseth (vascular and interventional neurologist at Oregon Health and Science University), Dr. Thomas Kent (professor and director of Stroke Research and Education, Department of Neurology, Baylor College of Medicine), et al: “Common etiologic consideration for the PCA stoke include cardiogenic embolization, atheromatous disease of proximal vessels resulting occlusion and/or artery-to-artery embolization, dissection of proximal vessels resulting in occlusion and/or artery-to-artery embolization, or intrinsic PCA atheromatous disease. Less common etiologies include migrainous cerebral infarction anterior circulation disease, hypercoagulable disorders, illicit substance use, vasculitides, and other rare stroke disorders … Rate of morbidity from PCA stroke is high. Recovery of visual field deficits may be limited. Patients may be unable to drive or read, resulting in major limitation in their quality of life, despite normal motor function … Although general alertness returns, prognosis for good functional recovery is poor because of severe memory dysfunction …” In order to determine the etiology: “After the stroke has been correctly identified and localized, the next step is to determine the mechanism by which the stroke occurred, as this WILL GUIDE LONG-TERM PREVENTIVE STRATEGIES. IN SOME CASES ALL DIAGNOSTIC POSSIBILITIES NEED TO BE CONSIDERED AND THE WORKUP IS EXTENSIVE.” “The treatment of stroke necessitates an understanding of the mechanism of stroke. The approach to stroke is defined by localization of the problem to determine the VASCULAR TERRITORY involved and subsequently by using the history, stroke subtype, and investigational tools to define the stroke mechanism … The management of acute stroke in general may be complicated and extensive. Various considerations need to be made regarding issues such as management of hypertension, hyperglycemia, cerebral edema with increased intracranial pressure …, deep venous thrombosis, myocardial infarction, and other stroke-associated conditions.” “Endovascular therapies are more likely to be used if there is significant vertebrobasilar disease … More recently, treatments such as vertebral artery stenting have been used and may replace the medical treatment-only approach to intrinsic vertebral artery disease.”

In conclusion, it was crucial to determine the mechanism of stroke and institute a recurrent-stroke prevention program as soon as possible for Mr. Y and based on best practice standards an angiogram was performed with hopes of having an immediate intervention. Please review the additional information attached and this comprehensive review in order to approve Mr. Y’s inpatient coverage for the dates of service 12/07–12/08 as the angiogram should not have been considered medically unnecessary and should not have been considered a delay or a “test” that could have been outpatient. Mr. Y deserved conclusive answers and the ability to have a preventative medical treatment plan established to help not only reduce his risk of recurrent infarction, but to help preserve his quality of life therefore helping contain costs that could be extrapolated from a future of adverse outcomes.

Please feel free to contact me if you have any questions.

Thank you,

Clinical Documentation Specialist

Health Information Management Department

County Medical Center

(123) 456-7890

Cc: PFS Director, HIM Director, Denial Coordinator

Sources: Author and Contributor Information for sources: ¹-Dr. Erek K. Helseth, MD; Dr. Thomas A. Kent, MD; Francisco Talavera, Pharm, PhD; Dr. Howard S. Kirshener; Dr. Helmi L Lutsep, MD (March 29, 2011). Posterior Cerberal Artery Stroke. Retrieved from .

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