News: Updated guidelines emerge for clinical validity reviews

The long-anticipated ICD-10-CM Official Guidelines for Coding and Reporting for fiscal year 2017 were released earlier this month, and include a definition for Exclude 1 notes, guidance for meaning and application of the word “with,” and clarification for laterality, according to an article by founding ACDIS Advisory Board member Gloryanne Bryant, RHIA, CDIP, CCS, CCDS in a recent ICD-10 Monitor article.

However, one other change raised some specific concerns for CDI specialists, says Laurie Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director for ACDIS and HCPro in Middleton, Massachusetts. The 2017 Guidelines contain new language regarding clinical validation:

“The assignment of the diagnosis code is based upon the provider’s diagnostic statement that the condition exists. The provider’s statement that a condition exists is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

While some are concerned that the new guideline will make clinical validation queries obsolete, the statement is aligned with recommendations provided in ACDIS Boot Camps and publications, Prescott says. “The confusion lies in the practice of clinical validation and understanding that this is different from the practice of code assignment.”

As the new direction states, code assignment is not based on clinical criteria, but rather on the provider’s statement that a diagnosis is present, says Prescott. When Recovery Auditors (RAs) started clinical validation reviews, many organizations changed their practices to avoid denials, choosing not to code specific diagnoses, even when they are stated by the provider.

“This practice concerned me, because coders and CDI specialists are not caring for the patient—we are merely reviewing the record,” Prescott says. “Just as we can only add a diagnosis to a claim if documented by the provider, we should never remove one from a claim because we disagree with the provider.”

If the diagnosis is not clinically validated, both RAs and commercial insurance auditors are going to deny the claim, according to Allen Frady, RN-BSN, CCDS, CCS, a senior consultant for Optum360, in a recent ICD-10 Monitor article. On the other hand, if the coder or the facility decides not to report the diagnosis, then they are in violation of the coding guidelines, which is also a major problem.

The new Guidelines come shortly after the release of a new clinical validation query practice brief in the July 2016 Journal of the American Health Information Management Association, available to AHIMA members on their website. The brief emphasizes the coder’s responsibility to become more clinically astute, and refer cases to a nurse or physician advisor as necessary, stating “[i]t appears clinical validation may be most appropriate under the purview of the CDI professional with a clinical background.” 

James Kennedy, MD, CCS, CDIP, director of CDIMD Physician Champions in Tennessee, says a properly trained and certified coder who is well-versed in clinical terminology and definitions should be able to have the conversation with the provider and not have to delegate this to another individual that may not be as experienced. “That said, if the coder is insecure with the situation, they should have a lifeline for clinical support as to ensure the validity of the documented diagnosis or treatment,” Kennedy says, in a recent JustCoding.com article.

Additionally, CDI specialists should be involved in clinical validation auditing, per AHIMA’s recommendation to audit a small sample of coded records each year to ensure coding professionals receive some clinical validation education, says Kennedy. 

CDI specialists should work with physicians to ensure the diagnoses documented are clinically supported within the record, and query if the documentation does not support a diagnosis, Prescott says. When a diagnosis does not appear to be valid, or is vulnerable to denial, and the physician strongly believes it is relevant, they should be instructed to clearly outline the reason to include this diagnosis within their documentation. Our job as CDI specialists is not merely to capture every diagnosis, but to assure the documentation within the record supports their presence.

“The new Official Guidelines for Coding and Reporting simply confirm that we must assign the appropriate codes as documented by the physician,” Prescott says.