Guest Post, Part 2: Where do we stand with clinical validation?

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

• Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
• Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

She also confirmed the new Guidelines addressed coding, not clinical validation, which is a separate function.

Coding Clinic, Fourth Quarter, 2016, pp. 147-149 also states that “coders should not be disregarding physician documentation and deciding on their own, based on clinical criteria, abnormal test results, etc., whether or not a condition should be coded.”

In other words, coders should not be accountable for clinical validation because they would not be expected to make clinically complicated judgments themselves.

Organizations must establish clear, compliant policies and processes for dealing with this clinical validation dilemma. Coders must be involved because they are responsible, as employees of the hospital, for ensuring that codes are assigned in compliance with the law, regulations, and coding Guidelines.

Therefore, organizations must continue clinical validation to ensure that documentation is complete and accurate, and that it appropriately reflects the patient’s clinical conditions, abiding by the statutes, regulations and policies that govern claims submission and reimbursement.

CDI programs that allow and encourage clinical documentation specialists and coders to collaborate and conduct clinical validation are the ideal institutional venue for ensuring compliant coding and claims submission that fully and accurately reflects the patient’s clinical condition and the circumstances of the admission.

Editor’s note: This article was originally published by Pinson & Tang, a CDI consulting company based in Houston, Texas. To visit their website, click here. In Part 2, the authors will further discuss implications of clinical validation reviews for CDI professionals. Click here to read a White Paper from the ACDIS Advisory Board on the matter.