News: ACDIS publishes clinical validation white paper

As CDI professionals and coders know, not all the words written in a health record translate nicely into ICD-10-CM/PCS or HCPCS coded data. As the role of coded data expands beyond statistical reporting and DRGs to accurate depictions of clinical scenarios, it’s becoming increasingly difficult to determine when a condition reaches a reportable threshold, according to a new ACDIS White Paper “Clinical Validation and the role of the CDI professional,” published on Monday, July 10. The paper aims to help standardize how CDI and coding professionals define and apply clinical validation techniques to accurately reflect clinical scenarios and minimize denials.

Medical necessity has always been a CMS and private payer requirement, but advances in technology and data mining techniques have made it easier for payers to identify claims vulnerable to payment errors as well as trends associated with questionable coding practices. Criteria used to determine patient status or validate a service as a covered benefit are often independent of code assignment, making it a challenge to address medical necessity vulnerabilities.

CDI professionals are uniquely positioned to unify efforts to report claims data that accurately reflects the clinical scenario and the provider’s intent within the confines of the code set. To fulfill this role, CDI specialists need to understand the role of clinical validation as it relates to payment denials and quality measure performance validation, the paper states

Although guidance regarding clinical validation abounds, it often seems contradictory and leads to struggles for both CDI and coding professionals. The new white paper seeks to clear some of the haze and help standardize this complex, important area.