Guest Post: Clinical validation denial targets

by Erica E. Remer, MD, FACEP, CCDS

Auditors target multiple conditions which for clinical validation denials (CVD). Personally, I found acute kidney injury (AKI) and malnutrition the most commonly defensible targets. On the other hand, I often agreed with auditors on their CVDs for pneumonia and urinary tract infections. Other frequent CVDs included sepsis, encephalopathy, and respiratory failure.

Certain diagnoses are susceptible to CVDs for the following reasons:

• DRG downgrade: Auditors target medical records with only one CC/MCC because doing so downgrades the DRG and results in less reimbursement.
• Empiric treatment: Providers start antibiotic therapy early for patients who present with signs of infection (e.g., fever, leukocytosis, altered mental status) on as they seek the infection’s source. Sometimes the physician cannot identify the source or the etiology of the disease turns out to be a different than originally expected. Clinicians also need to be careful to not propagate the original debunked diagnosis via copy and paste, so it gets wrongly coded.
• Documentation consistency: Physicians should document their medical decision making process throughout the patient’s stay. Best practice is to document when a diagnosis is initially considered (may be in uncertain format), when the diagnosis is definitively ruled in, and when the condition resolves. The physician should recap this information in the discharge summary. Only mentioning a diagnosis once in the medical record, while permissible, raises an auditor’s interest and begs the question of whether the condition really was present.
• Pursuant to a query: When providers need to be queried to make a diagnosis codable, and they agree without supplying any clinical support, a red flag goes up—and I mean like waving one in front of an auditor like a bull, and not just signaling peril up ahead.

Finally, auditors target diagnoses with uncertain or emerging clinical guidelines. Clinical guidelines change, but it takes time for medical practice to adjust (e.g., malnutrition, sepsis). If a guideline is not universally adopted (for example, discussions regarding the new Sepsis-3 definitions) some variability in medical practice is allowed. That doesn’t necessarily mean a provider is wrong if he or she does not follow the latest guideline. As long as the provider is within the acceptable range of practice, he or she just needs to demonstrate the clinical considerations of the case and the auditor should accept the diagnosis. If a provider deviates from clinical criteria or guidelines, he or she should document the mitigating circumstances (e.g., on beta-blockers, previous antibiotic therapy, contamination).

On the other hand, the provider needs to consider established guidelines. If the average, prudent similarly qualified practitioner wouldn’t call an asymptomatic deviation of sodium by 1 mEq/L, hyponatremia, neither should you.

Similarly, AKI has criteria of change within the previous 48 hours, or deviation from a baseline from seven days ago, but a provider could make a convincing argument that the patient’s serum creatinine (SCr) is always X and the acute derangement is likely to have occurred since the onset of symptoms 36 hours ago. It would be quite serendipitous to randomly have a baseline drawn within seven days of an index visit if AKI preceded hospitalization, wouldn’t it? However, if the SCr is only off by 0.1 mg/dL, you are hard-pressed to spin that as AKI.

While the coder may not really the arbiter of clinical validation, coders should be empowered to refer questionable records for a clinical review either by the CDI specialist, the attending, or a physician advisor/champion, and coders need to know which conditions are vulnerable and which clinical indicators to consider.

Absence of abnormal clinical indicators does not mean the condition is definitively not present; it means the encounter needs clinical review and the condition may require more documentation to support it.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com. For the third part of this article, return to the blog next week!