Note from the ACDIS Editor: Clinical validation conundrums

By Linnea Archibald

According to a poll on the ACDIS website last summer, 73% of respondents perform clinical validation reviews, yet advice for these reviews has long been murky for CDI professionals.

Despite the sparse and often contested guidance on the subject, CDI professionals are thrown into the fray of clinical validation reviews and queries, in part because of the current denial landscape. Though code assignment “is based upon the provider’s diagnostic statement that a condition exists,” it doesn’t stop external auditors from denying the reported codes because of lackluster documentation in the medical record.

Though CDI professionals have often interpreted the guidance above to mean that clinical validation queries are obsolete, that’s a misunderstanding, according to Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI education director at HCPro in Middleton, Massachusetts. The confusion lies in the difference between code assignment and the practice of clinical validation, she says.

So, if the current denials landscape shows an increase in clinical validation denials, the guidance allows for clinical validation queries, and the majority are already conducting these reviews, what’s the most compliant practice for CDI to follow?  

Like all queries, clinical validation queries have to follow the ACDIS/AHIMA practice brief, “Guidelines for Achieving a Compliant Query Practice.” CDI professionals study these recommendations early in their careers but need to pay particular attention to the rules as it relates to clinical validation and the formulation of non-leading queries.            

CDI professionals cannot question the physician’s diagnostic ability or clinical assessment of the patient’s condition. A clinical validation query really asks whether the treatment supports the documented diagnosis, said Cheryl Ericson, MS, RN, CCDS, CDIP, manager of clinical documentation services at DHG Healthcare in the Charleston, South Carolina area, during the clinical validation workshop last week. “We’re just making sure that if someone else looked at the record, they would agree that that code is substantiated.”

Of course, physically crafting a clinical validation query can be tricky for even seasoned CDI professionals. As with any query type, you need to include the relevant clinical indicators, said Cathy Farraher, RN, BSN, MBA, CCM, CCDS, a CDI specialist at Newton-Wellesley Hospital in Newton, Massachusetts, reminded participants in last week’s workshop,.

“[Include] anything that’s relevant,” she said. For example, “if you’re looking at a malnutrition clinical validation query and the patient is noted to be well nourished and eating 100% of his or her meals in the nurse’s notes,” that should be included.

Clinical validation should be a part of CDI professionals’ jobs, according to Farraher, because “our job is to ensure that whatever codes are sent out are the most specific and accurate ones.”

For additional information, review the following resources:

• “CDI Workshop: Unpack Clinical Validation Efforts and Query Practices”
• “Q&A: Clinical validation of sepsis”
• “Guest post: Querying for clinical validity” 
• “White Paper: Clinical validation and the role of the CDI professional”

Editor’s note: Archibald is the editor at ACDIS. Contact her at larchibald@acdis.org.