March Madness: Defending Against Medicare Advantage Denials for Encephalopathy

March brings excitement of the men’s and women’s Division 1 NCAA tournaments. However, for those dealing with payment denials from Medicare Advantage companies, another concern looms large: the denial of payments for diagnoses of encephalopathy, including metabolic encephalopathy (G93.41), other toxic encephalopathy (G92.9), and unspecified toxic encephalopathy (G92.8). These codes are classified as Major Conditions and Comorbidities (MCCs), making them prime targets for payment denial when encephalopathy is the sole MCC for the MS DRG. Denying payment for this single MCC can significantly reduce the relative weight of the MS DRG, leading to a substantial drop in payment, particularly for surgical MS DRGs.

 

The Challenge of Clinical Definitions

Understanding and applying the clinical definitions for metabolic encephalopathy, toxic encephalopathy, toxic metabolic encephalopathy, and delirium can be challenging at any time of the year. The broad definitions and lack of widely accepted criteria make converting clinical documentation to a clinically valid ICD-10-CM code difficult. Medicare Advantage companies often exploit this uncertainty to deny payments.

 

Encephalopathy in Complex Patient Cases

Adding to the complexity is the fact that acute encephalopathies can occur in patients with preexisting chronic brain conditions such as dementia and psychiatric illnesses.

Patients admitted to an acute care hospital may present with or develop acute encephalopathy during their stay. The term “acute” indicates that the encephalopathy has developed in less than four weeks. When acute encephalopathy is present, the clinical evaluation focuses on determining its cause, often involving brain imaging. Identifying and reversing the cause can improve brain function. For example, metabolic encephalopathy (G93.41) may be caused by a sodium level of 119 mg/dl, while toxic encephalopathy (G92.9) can result from an adverse reaction to a drug, such as the antibiotic ciprofloxacin. Toxic metabolic encephalopathy, also referred to as other toxic encephalopathy (G92.8), poses a particular challenge, as matching the clinical documentation to the cause can be difficult.

 

Why Medicare Advantage Denies Payments

Medicare Advantage companies may deny payment for acute encephalopathies for several reasons. The most straightforward and common reason is inconsistent documentation regarding the patient’s mental status. Descriptions of the patient as alert and oriented throughout the hospital stay can lead to denial. Additionally, the absence of a clinical narrative detailing the patient’s improvement to or near their baseline mental status due to the correction of the underlying cause of the acute encephalopathy may result in a clinical validity denial.

 

A Defensive Strategy Against Denials

An effective defense strategy involves reviewing payment denials for acute encephalopathies, understanding the tactics used by Medicare Advantage companies, and providing doctors with actionable information to create clinical narratives that resist denial attempts. Whether employing a zone or man-to-man defense, a well-informed approach can reduce denials. By blocking some shots and securing defensive rebounds, you can mitigate the madness of March.