Book excerpt: Clinical validation reviews in today’s denials landscape

by Chris Simons, MS, RHIA

Although managing accurate principal diagnoses and CC/MCC assignment is always going to be a focus for CDI professionals and coders (along with clarifying general documentation inconsistencies). Clinical validation denials are on the rise, making record reviews focused on clinical discrepancies an increasing focus for those working in the field.

A clinical validation denial occurs when the physician documents a particular diagnosis but the payer disagrees that the information in the medical record supports that diagnosis. Coders are instructed to code diagnoses as documented and query inconsistencies but are also taught not to question the diagnosis assignment itself, or the physician’s medical decision making.

Nevertheless, auditors may reject the reporting of a diagnosis, even if documented, as not clinically supported.

Your staff can help strengthen the support for the reported diagnosis through formal or informal queries. Focusing on those diagnoses known to lead to denials (sepsis, respiratory failure, protein calorie malnutrition, and encephalopathy are commonly denied on these grounds) can be a good strategy.

Inpatient coders and CDI specialists often find informal dialog with the medical staff to be the most effective when communicating documentation shortfalls. While these informal dialogs should still be documented (in your software or even a spreadsheet) for tracking purposes, the informal query has the advantage of being more collaborative and allowing for more education of the medical staff regarding coding rules and documentation requirements. Relationship building is very important here.

Editor’s note: This article was adapted from content originally included in The Contemporary Guide to Health Information Management.