Note from the Instructor: End clinical validation push back

By Allen Frady, RN-BSN, CCDS, CCS, CRC

We’re all very familiar with the reasons for not doing clinical validation—we shouldn't question the physician, diagnostic medicine is hard, etc.

Past clinical validation methods often used open-ended queries phrased as “please document the clinical significance of the findings.” These were not only useless in their efficacy, but also difficult to understand and essentially a waste of everyone’s time. That era brought us things such as acute respiratory failure on every post-operative patient and massive amounts of fraud and abuse.

I don't want to have too heavy a hand here, but the reality is that clinical validation is required for compliance’s sake, period. Let’s look at the official guidance.

The ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice brief states that when a provider documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, they should be queried (2013 and 2016 versions). The AHIMA Standards of Ethical Coding require that only accurate and valid codes are reported. AHA Coding Clinic, Fourth Quarter, 2017, p. 110, states that if the attending physician affirms that a patient has a condition despite certain clinical parameters not being met, the facility should request the physician document the clinical rationale and be prepared to defend the condition if audited.

The Official Guidelines for Coding and Reporting, published by CMS, states that the Uniform Hospital Discharge Data Set (UHDDS) defines the attending provider as the clinician of record at the time of discharge and goes on to state that the list of diagnoses in the patient record is the responsibility of the attending provider. AHA Coding Clinic, Third Quarter, 2016, p. 26, states that it’s the responsibility of the attending physician to gather and collate all (not some) of the findings from the consultants and other providers involved in the care of the patient and that the plan of care is based on the attending physician’s evaluation, interpretation, and collation of all (not some) of the findings (pathology, radiology, and lab). (I assume here that they mean the abnormal findings as one would not expect much documentation about normal findings.)

Remember, all this guidance comes from the official cooperating parties that legally set the rules and standards for coding and billing.

Physicians sign a condition of participation with CMS and the False Claims Act has an exhaustive legal explanation of the requirements that any billing done with the United States government requires accurate and precise delivery of goods with zero tolerance of incorrect billing practices. In theory, this includes both under and over billing. You are liable for a false claim if you knowingly make a false claim, false record, or false statement to get a claim made. If you have actual knowledge, deliberate ignorance of the truth, or reckless disregard of the truth you are also liable.

One could easily make the argument that diagnoses reported without clinic indicators meet the legal definition outlined above violating the False Claims Act. You could also make a similar argument when a provider refuses to provide a diagnosis that is clearly present (albeit, you would need a review and verification by another licensed physician in either direction for final ruling). For reference, see this governmental page on the False Claims Act.

The physician may feel they aren’t really held legally accountable for unsubstantiated or missing diagnoses when the clinical indicators are present due to the difficulties of diagnostic medicine, but unfortunately for the provider (and everyone else involved), the facility at which the patient receives the care is being held to a legal standard.

From the perspective of a facility employee, it seems clear what the legal requirement of a CDI specialist is in this regard. This is about compliance, not scope creep. Be that as it may, it would probably be best practice to funnel the above information through your physician advisor and legal/compliance departments rather than taking on the physician directly in a battle.

Editor’s note: Frady is a CDI education specialist for HCPro in Middleton, Massachusetts. Contact him at AFrady@hcpro.com. For information regarding CDI Boot Camps, visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.