CDI Field Guide to Denial Prevention and Audit Defense, Second Edition

CDI Field Guide to Denial Prevention and Audit Defense, Second Edition

Trey La Charité, MD, FACP, SFHM, CCS, CCDS
Reviewed by John Pettine, MD, FACP, CPHQ, CCDS

How can your CDI program help defend your facility’s medical records and claims submissions from recovery auditors to ensure the facility receives the appropriate reimbursement for its patient care?

The world of denials prevention and audit defense is filled with a host of watchdog agencies that audit claims and take back funds for inappropriate submissions. Your hospital must work to protect its reimbursement, and your CDI program can help. Author Trey La Charité, MD, FACP, SFHM, CCDS, provides tips and strategies to  help your program improve its denials prevention efforts.

The CDI Field Guide to Denial Prevention and Audit Defense, Second Edition helps CDI professionals understand the role of recovery auditors in private and governmental reimbursement efforts, various audit contractors and their scopes of work, and the importance of CDI and query compliance in denials prevention. La Charité also explains how to identify possible documentation risk associated with the growing use of electronic health records as well as how to establish an effective appeals process at your organization.

This second edition features new content, including:

• A chapter focused on defending against clinical validation denials for specific diagnoses
• An epilogue detailing one organization’s yearslong appeal journey
• Sample appeal letters for some of the most commonly denied diagnoses 

Published: August 2023

Page count: 150
Dimensions: 8.5 x 11 Print, perfect bound
ISBN: 978-1-64535-267-9

Table of Contents

• Chapter 1: The World We Live In
• Chapter 2: Big Brother is Watching
• Chapter 3: Stay Between the Lines
• Chapter 4: How the Recovery Auditor Sausage is Made
• Chapter 5: Manning the Barricades
• Chapter 6: How to Prevent Recovery Auditor Denials
• Chapter 7: Electronic Health Record Myths and Minefields That Benefit Recovery Auditors
• Chapter 8: Constructing Successful Appeals
• Epilogue
• Appendix: Sample Appeals Letters

About the Author

Trey La Charité, MD, FACP, SFHM, CCS, CCDS

Trey La Charité, MD, FACP, SFHM, CCS, CCDS is the medical director for CDI and coding at the University of Tennessee Medical Center (UTMC) in Knoxville. A past ACDIS Advisory Board member, he is also a regular presenter at the annual ACDIS meeting and the pre-conference The Physician Advisor’s Role in CDI.  He has published and presented extensively in the field of CDI, addressing physician advisor training, program management, recovery auditor appeals, clinical criteria, and coding conventions. He is board certified in internal medicine, has been a practicing hospitalist for over 20 years, and is a clinical assistant professor in the Department of Medicine, dedicating his clinical time to resident physician education. He has additional responsibilities at UTMC including case management, utilization review, medical records, compliance, and performance improvement.

About the Reviewer

John Pettine, MD, FACP, CPHQ, CCDS

John Pettine, MD, FACP, CPHQ, CCDS, is the vice president of clinical documentation integrity services for Lehigh Valley Health Network (LVHN), a 13-hospital system in Allentown, Pennsylvania. His responsibilities include oversight of the CDI and utilization review (UR) departments, UR medical director, and all physician advisors. Since first appointed as medical director of CDI in 2009, he transformed a small CDI project into an expansive multifunctional network department. Over the past 14 years, he has amassed extensive experience in all aspects of CDI and physician advisor management and duties. He has expertise in leading and creating CDI provider and department education, program management, network clinical criteria and definitions, and strategies for management of denials and appeals, including utilizing payer relations and contracting solutions. He is board certified in internal medicine and has been practicing for over 24 years at Lehigh Valley Hospital, with both inpatient and outpatient service. He is the former chair of LVHN’s Health Record Governance Committee and has served on numerous quality, CDI, department of medicine, health information technology, and health information management committees. He is an original member of the ACDIS Physician Advisor Mastermind group and the ACDIS Physician Advisor Exchange.