CDI tip: The role of clinical validation in CDI

by Kathryn Fallah

Back in the day, the medical record review process consisted of the following steps: a provider documenting a diagnosis, coders coding and reporting it, and the facility getting paid. No further questions were asked about the validity of the diagnosis submitted. Eventually, CMS’ Recovery Auditors and private payers jumped in, denying payments and questioning claims. These clinical validation denials—denials not based on the accuracy of ICD-10-CM/PCS or MS-DRG assignment but on the veracity of the diagnosis—made it necessary for CDI staff to seek out documentation within the medical record to clinically support the validity of a diagnosis. As Dawn Valdez, RN, LNC, CCDS, CDIP, a CDI education specialist for HCPro, introduced in a recent presentation, clinical validation is now a core responsibility of CDI programs. After all,  the False Claims Act states that claims billed must be clinically valid, she said, and querying for clinical validity protects the facility and contributes to an accurate final bill. 

Being a beginner to CDI, I understood the general idea of submitting a valid claim, but that made me wonder; what exactly is the process of clinical validation, and how do you ensure that a diagnosis is valid? Auditors check a facility’s claim for the medical necessity of care and to verify the diagnosis is accurate. Valdez offered an example that explains this idea perfectly. Paying for an incorrect or inaccurate diagnosis is like ordering a hamburger and being billed for a steak, she said. Nobody wants to pay for something they never received. Healthcare is no different.

Clinical indicators are the evidence that a condition exists, such as symptoms which support the reason a diagnosis. Asking physician to use the phrase “as demonstrated by” encourages them to include supporting evidence more likely to lead to a closed case and protect the claim from denial. If a diagnosis is vague, missing, or incomplete, CDI specialists can use clinical indicators to support a query to the physician requesting a more explicit diagnosis, Valdez said.

For instance, a provider documents a “severe protein-calorie malnutrition” in the patient’s H&P (history and physical). In the notes, the provider describes the patient as “well developed” and “well nourished” on a physical exam with a regular diet ordered, no dietician assessment included, and no information regarding chronic illness, weight loss, or edema. Since the diagnosis and clinical criteria conflict, it is appropriate to query. A CDI specialist would present the clinical indicators documented (i.e., “well developed” and “well nourished”), to support the query and request the physician provide additional details related to the diagnosis within the medical record.  

CDI teams can improve their clinical validation process by targeting their top 10 denial vulnerable diagnoses. Alongside this, creating organizational definitions of diagnoses collaboratively with coders, medical staff, and CDI can aid in the clinical validation process and determining if a minimum threshold of support is present in the health record.

Editor's note: The information in this article was derived from a PROPEL CDI presentation. Fallah is a PROPEL CDI member liaison. Contact her at kfallah@blr.com.