Writing Effective PRO Rebuttals
By Roger P. Holland,
MD, Ph.D
President, PRO Utilization
Despite our best efforts at coding, the PROs still send out either Notices of Admission Denials, Notice of DRG Changes, or Notices of Potential Quality Concerns. Frequently the responsibility for responding to one or all of these Notices falls on the shoulders of the Health Information Management [HIM] Departments. Ideally, Notices of DRG Changes should be handled by the DRG Coders, Notices of Admission Denials by Utilization Management in concert with the Attending Physician, and Notices of Potential Quality Concerns by the Attending Physician, in concert, perhaps, with the Physician Advisor, if one is available. Nevertheless, if you have to be the one to respond, here are some proven techniques that I have gathered both as a Physician Consultant [PC] for Medicare - one who read the rebuttals and then acted upon them - and as a consultant who actually composes many rebuttals on behalf of hospitals for a number of PROs including Medicare, Medicaid and Blue Cross.
1. Follow the format of the Notice Letter carefully. Address it to the proper individual or department, i.e., Bureau of Appeals, etc. RE: Notice of Potential DRG Change - Jones, Mary S. Reference # 12345678 Medical Records # 987654 Date of Admission 01/01/95 " Dear Dr. Green" or if no specific individual signed the Notice address it "Dear Colleague".
2. Restate briefly the PROs change: "I am in receipt of your letter dated 05/05/95 in which you changed our original PDX from 410.91 to 414.9. This resulted in a change in our original DRG from 122 to DRG 140.
3. Restate the PROs exact words whenever possible. "You stated that: 'CPK isoenzyme levels were normal and therefore acute myocardial infarction is not supported by the medical record.'"
4. Next restate clinical information in the medical record that refutes or corrects the PRO's specific reasoning: "I refer you to the Attending Physician's progress note of 01/02/95 in which he states: "Patient's onset of pain three days earlier with accompanying dyspnea suggests that the actual MI was sustained 3 days earlier" or "Patient has a large hematoma to the right thigh. CPK levels are expected to be elevated irrespective of cardiac damage".
5. Look for coding inconsistencies in the PROs new listing of the PDX and CCs. For example, if the PRO moved 410.91 to a Secondary Diagnosis position then point it out to them. "Although you changed our PDX to 414.9, you included 410.91 as a Secondary Diagnosis. You acknowledge therefore that it was present on admission. From this position you then take one or both of the following tactics:
(a) Argue from the point of an authoritative source. "Coding Clinics, 4th qtr, 1996 indicates that when Unstable Angina is attested to along with AMI, the AMI should be listed as the PDX."
A DRG optimizer, such as the one I use, Clinical Coding Expert from Information Resource Products, Inc., Wilmington, Massachusetts, is especially helpful in supplying you with an authoritative source from which to succinctly quote or reference. Their CliniGuide provides you with on-line reference to coding principles, HCFA PRO questions and references to AHA Coding Clinics.
Remember that although the PRO nurse reviewer that arrived at the DRG. Change may be familiar with Coding Rules, often the PC, who reads the rebuttal is not. Appealing to a higher authority is a powerful rebuttal technique. This is exactly what a car salesman does to you when he says: "I don't know if we can meet your price. I'll have to go and speak to my Sales Manager for approval." Reflect on how his appealing to "higher authority" makes you feel. That's the same feeling or state you have placed the PRO's PC;
(b) "Since you acknowledge that the patient had an acute MI during this admission, by including it as a Secondary Diagnosis (CC), when did this event occur, if it was not 'after study' responsible for the patient's admission?" This last approach places the burden of proof back to the PROs. It is also very powerful. I've had instances where the PDX was 507.0 Aspiration Pneumonia and the CC was 491.21 Exacerbation of COPD. The PRO switch the PDX and the CC around and then changed the Aspiration Pneumonia to 486, Pneumonia, but kept it as a CC. The argument I made was identical to that illustrated above: "Since you have kept our original PDX as a CC, if it was not reasonably present at the time of admission, when exactly did it develop? And, what is your rationale for categorizing it as only Pneumonia and not the attested diagnosis of Aspiration Pneumonia?"
6. Add and abstract any additional clinical information from other sources (clinic notes, previous admissions, subsequent admissions, etc.) which is pertinent to the issue at hand: "This patient has had prior admissions for acute MI's which presented with near identical scenarios of dyspnea, EKG changes and positive Technicium scans on 02/02/93 and 04/04/94." "Subsequently patient was re-admitted for a cardiac catherization on 02/02/95 which showed complete blockage of the posterior circumflex artery and akinesis of the posterior wall of the left ventricle. She thereafter underwent emergency CABG and died of cardiogenic shock within 48 hours of that admission." Do not include copies of these admissions. If the PRO wants it, they'll request it. The attestations from these admissions are already in their computers.
Also, do not add irrelevant information. "Patient also suffers from Alzheimer's Disease and has chronic decubiti at the coccyx." This is the "kitchen sink" approach and always weakens your case.
7. Use the complete medical record. One insurance PRO I'm aware of requests only the History & Physical and Discharge Summary, along with the attestation to arrive at the final diagnosis sequencing and DRG assignment. We know that physicians do not always include all the relevant information in their discharge summaries. In these instances only include a photocopy of the relevant blood culture report, cardiac Echo report, etc. I do not recommend sending the PRO copies of information that they already have on hand. When I was a PC I did not appreciate receiving more information than I needed or copies of information I already had in my possession.
8. Get the Physician to sign the Rebuttal letter. PROs give much greater consideration from a rebuttal signed by the Attending Physician or any physician, than they do to the Health Information Management individual who actually composes the letter. This may not be fair, but it is a fact of life, just the same. When the Attending Physician signs the letter, you can include the following powerful sentence: "It is my professional opinion based upon my clinical experience that Mrs. Smith sustained an acute myocardial infarction and that was the reason for her inpatient admission." The PROs do not like to directly contradict an attending physician's appeal to his clinical experience. Now some physicians are loath to make such a statement as they feel that it will draw closer attention and scrutiny to their medical record and may possibly elicit a Notice of Potential Quality from the PRO reviewer. This is very unlikely. The chart has already been reviewed for quality. The PC is only going to address the issue of a DRG Change and nothing more.
9. Finally, request that the chart be reviewed by another Physician Consultant with the same area of specialization as the Attending Physician. Many of the PCs for the PROs are specialists looking for extra work in a time of decreased income due to competition from Managed Care. If you don't ask for another PC, you'll most certainly get the same PC who sent you the first Notice of Potential DRG Change. The second tier of PC's review much fewer Medical Records and, therefore, the tactics listed above are much more likely to be successful with them than with the original PC.
Whatever you do, don't get discouraged by a Notice of Potential DRG Change. It does not necessarily reflect on either your accuracy or your integrity as a DRG Coder. With each successful rebuttal, you'll increase your confidence for the next one. By the way, keep a copy of all your successful rebuttals and compute the difference in DRG reimbursement to your facility because of your success. Comes in very handy at the time of your performance review or your interview for another (higher-paying) position!
Dr. Roger Holland is President of Utilization PRO headquartered in Tyler (903-581-3901). His company provides Physician-Assisted strategic and tactical ideas, education and alliances for increasing reimbursement, decreasing costs and improving patient care. Dr. Holland utilizes Clinical Coding Expert on a 486DX Notebook computer for his on-site DRG validation, optimization and training.