ACDIS tip: Educating physicians on clinical validation processes

By Cheryl Ericson, RN, MS, CCDS, CDIP, and Cathy Farraher, RN, MBA, CCM, CCDS

Without a team that is fully engaged, it is impossible to maintain a compliant organization in terms of documentation. As time passes and clinical teams become more accustomed to, and comfortable with, the clinical validation process, less formal approaches may be possible.

At the outset, however, all treating physicians need to understand:

• How the need for a clinical validation query is determined
• How queries should be answered
• How they should respond if they disagree with the premise of the query
• Whether queries are considered part of the medical record
• The consequences for not answering a query
• The expectations for physician compliance and cooperation with CDI efforts

Other educational topics include how:

• Data are used to create physician quality and efficiency profiles
• Physician profiling is used to negotiate payer contracts
• Documentation influences severity of illness and risk of mortality measures
• Basic hospital reimbursement, including length of stay, relative weight, inpatient versus outpatient documentation, medical necessity, and Recov­ery Auditor efforts
• Certain conditions constitute hospital-acquired conditions
• Documentation of present on admission status matters for final coding
• Complication documentation affects code assignment, reimbursement, and quality scores

Editor’s note: This article is an excerpt from Ericson and Farraher’s new book, Clinical Validation Reviews for CDI Professionals. To listen to a webinar with the authors on the topic of clinical validation, click here.