Q&A: No clinical indicators identified within the medical record

Q: Can we use the phrase “no clinical indicators identified” on a clinical validation query?

A: The physician documentation of the diagnosis itself could be considered a clinical indicator. However, CDI professionals need to ensure that diagnosis is supported by the clinical evidence within the medical record. That’s what clinical validation efforts are all about.

Consider this excerpt from the ACDIS/AHIMA 2019 Guidelines for Achieving a Compliant Query Practice (see p. 7):

The purpose or type of query will also impact how much clinical support is necessary to justify the query and, when applicable, reasonable option(s). When the purpose of the query is to add a diagnosis, clinical indicators should clearly support the condition, allowing the provider to identify the most appropriate medical condition or procedure.

The quality of clinical indicators—how well they relate to the condition being clarified—is more important than the quantity of clinical indicators. [Emphasis added.]

Additionally, ensure all normal values that could be clinical indicators are identified. CDI specialists often overlook normal values as clinical indicators for a clinical validation query because they are so accustomed to looking for the abnormal ones.

If you use the MEAT (monitor, evaluate, assess, and treat) pneumonic, use those categories to identify the clinical indicators not documented. According to a March 2018 AAPC article called “Include MEAT in Your Risk Adjustment Documentation,” MEAT represents:

• M – Monitoring signs, symptoms, disease progression, disease regression
• E – Evaluating test results, medication effectiveness, response to treatment
• A – Assessing/Addressing ordered tests, discussion, review records, counseling
• T – Treating medications, therapies, other modalities

Also, there is nothing wrong with including a statement within the query that the reason for the query is a lack of supportive clinical indicators.

Query Example

Disclaimer: The below criteria are used as examples to demonstrate what CAN be done on clinical validation query when there appears to be an absence of clinical indicators. The below query is not mandatory in regard to its length but rather is used to illustrate the possibility of options for clinical indicators in a CV query.

Dear Dr. X: Chronic systolic heart failure is documented in the progress notes however there is a lack of clinical indicators noted within the documentation. Please see the below information:

• H/P: “Chronic systolic/HF”
• MARS: Heart failure related medications are not identified in medication administration record; there is no indication of low dose coreg, other beta blockers or diuretics ordered for this encounter
• ECHO: Not ordered during this encounter, PMH for chronic HF of any type is not noted for prior admissions within the electronic health record
• CXR: Not ordered this admission, no PMH noted in medical records
• Lab: BNP was not ordered for this admission. BNP does not appear to be ordered for any prior admissions in the electronic health record

Based upon the limited information listed above, do any of the following apply:

• Chronic systolic heart failure ruled out
• Chronic systolic heart failure ruled in- please provide supportive clinical indicators
• Other, please specify
• Unable to determine

In conclusion, using the MEAT pneumonic on the clinical validation query above, we can determine the following:

• M: Regarding monitoring for chronic systolic heart failure, there were no signs, symptoms, disease progression, disease regression noted in the medical record for this condition.
• E: Regarding evaluating test results, medication effectiveness, response to treatment, there were no tests or medications specific to chronic systolic heart failure identified within the documentation.
• A: Regarding assessment, ordered tests, discussion, review records, or counseling, it does not appear that there was any focus or discussion relating the condition of chronic systolic heart failure.
• T: Regarding treatment of the condition of chronic systolic heart failure, there were no medications, therapies, other modalities ordered during this encounter.

When it comes to a lack of clinical indicators, there are usually more than we see at first glance. If the standard treatment for the condition is not documented as given nor ordered, that is a clinical indicator. If there was no evidence of a provider focus regarding the related physical assessment of body system(s), that is a clinical indicator as well. If normal routine diagnostics for the condition were not performed, that is also a clinical indicator, etc.

Clinical validation queries continue to be tricky for CDI specialists. I recommend using the pneumonic included in this article on difficult cases where clinical indicators are not easily identified to see if what’s not being said or done are actually clinical indications of a lack of support for the condition in question.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.