Denial Smackdown Volume One

Making a distinction between acute and chronic blood loss anemia is important.

It is crucial to recognize and document acute blood loss anemia because the condition is a significant indicator of severity of illness impacting revenue, quality and performance metrics, and pay-for-performance measures.

You can click here for examples.

In the United States, the diagnosis of an adnexal or pelvic mass will occur in 5 to 10 percent of women in their lifetime. Although commonly benign, the risk for malignancy in an adnexal or pelvic mass increases with age.

This month’s Denial Smackdown, featured the case of a patient who suffered a 6-point drop in their hematocrit post operatively, experienced a 200 ml blood loss intra operatively, had significant adhesions noted intra operatively, developed tachycardia and hypotension post operatively and was diagnosed as having “acute blood loss anemia” by the attending gynecologist post operatively.
You can imagine our dismay with this denial for acute blood loss anemia.

Payer: UnitedHealthcare
Billed DRG: 742 Uterine & adnexal procedures for non-malignancy with CC/MCC
Proposed DRG: 743 Uterine & adnexal procedures for non-malignancy without CC/MCC
At Risk Dollars: $2542.17
Recovered Dollars: $2542.17
Disputed Diagnosis: ACUTE BLOOD LOSS ANEMIA (ICD10-CM D62)
What made this denial so outrageous

An anonymous reviewer diagnosed the patient with “hemodilution”. Common sense says that adding a medical diagnosis to a record constitutes the practice of medicine.
Evidence based literature cited by Appeal Masters to overturn the denial

Bleeding and Acute Blood Loss Anemia as found on:

“Even if the amount of blood lost following surgery is expected and routinely associated with the procedure, acute blood loss anemia is still present if anemia occurs.”

Additional arguments made by AppealMasters

“Discounting the clear and consistent documentation in the chart from the attending and physician as set forth (above) and substituting an alternative diagnosis as a cause of a patient’s symptoms or findings (significant drop in hemoglobin, notable adhesions intraoperatively, tachycardia and marked hypotension postoperatively which the attending physician clearly diagnosed as acute blood loss anemia) infringes dangerously close, if not in fact actually crossing the line of practicing medicine under most state statutes related to medical practice. It is concerning that the reviewer offers no credentials to confirm their qualifications to diagnose medical conditions.”


Initially billed DRG 742 and the diagnosis of acute blood loss anemia (ICD-10CM D62) “Acute Blood Loss Anemia” were validated as correctly coded and billed.
What You Can Do In Situations Like This

Make certain that you demand the reviewer’s credentials.
Make your manage care contracting and legal departments aware of the concerns that the removal or addition of a diagnosis entered by an attending healthcare provider in some states could be viewed as practicing medicine.
Engage your organization to report behavior like this to State Medical Boards and State Insurance Commissioners.
Keep good data regarding which companies engage in this behavior most frequently and work with your legal department to consider legal options to push back.
Stand up for your rights!

Would you have handled this situation differently?

We want to hear from you! Take this quick poll to tell us what literature you would’ve used or arguments you would have made. Please feel free to share with colleagues. We will combine answers and share in next month’s Denial Smackdown!