Note from the Instructor: The importance of clinical validation in CDI

by Dawn Valdez, RN, LNC, CDIP, CCDS

The False Claims Act of 1863 imposes penalties on anyone who submits a “false claim” for services that were not actually performed. In healthcare, that means CMS needs to check that all services billed are clinically valid and the patient received the treatments needed for their condition.

The check and balance to prevent false (erroneous) billing is clinical validation.

In 2016, AHIMA published Clinical Validation, The Next Level of CDI stating that:

“As healthcare continues to evolve and quality of care is tied to claims data and payment methodologies, payer expectations regarding what clinical documentation elements are necessary to support a claim have shifted. The goal of CDI and HIM coding professionals is to ensure the patient’s clinical scenario is accurately captured in the health record.”

Additionally, according to the 2017 ACDIS white paper Clinical validation and the role of the CDI professional:

“Traditionally, the query process has focused on adding specificity to an already-documented diagnosis or obtaining a diagnosis based on clinical evidence within the health record. However, providers are increasingly documenting diagnoses without corroborative clinical evidence. [And so] some argue that CDI professionals [need to] address clinical validity issues with each record review, making clinical validation inherent to the CDI process rather than an additional function.”

CDI specialists have always used clinical indicators to identify documentation discrepancies or a missing diagnosis. When it comes to applying clinical validation techniques, there is a missing piece for many CDI specialists. While most agree retrospective reviews are ideal for clinical validation, it is less than ideal for providers to receive queries after the patient is discharged. Yet, I’ve witnessed a few common struggles with concurrent reviews related to clinical validation.

The first obstacle? Concerns that providers think CDI specialists are questioning their judgement. It’s a valid concern. However, CDI specialists have offered educational tips on the differences between commonly used medical terminology and coding terminology for years.  The clinical validation process is very similar. AHIMA addresses this dilemma within its 2016 paper stating:

“When a query professional writes a clinical validation query, . . .they are highlighting a potential gap between a documented diagnosis and the clinical evidence in the health record. The diagnostic decision remains the responsibility of the treating provider.” 

The 2016 AHIMA brief goes on to state:

“Issuing a clinical validation query is simply requesting that the practitioner to confirm the presence of the condition and provide additional rationale for common scenarios such as: 

• A diagnosis was documented, but the patient has an atypical presentation

• A diagnosis appears to lack the clinical indicators needed to meet organizational or payer criteria

• A documented diagnosis appears to be no longer valid, but the documentation does not show the condition as ruled out/eliminated/resolved.”

In 2011, CMS answered this question in its Recovery Auditor Scope of Work statement, describing clinical validation as: “The process of validating each diagnosis or procedure documented within the health record, ensuring it is supported by clinical evidence” 

The second issue? Training. In most parts of the country, formal CDI training and awareness of the clinical validation process can be incongruent. CDI specialists are trained to identify abnormal values within the record. They weren’t picking up on normal values that could negate the presence of a documented diagnosis. Training and habit were preventing many CDI specialists from detecting clinical indicators that did not support the presence of the diagnosis within the documentation. 

To correct this finding, CDI specialist must broaden their focus if we are to be successful in identifying gaps in documentation that fail to support diagnoses. 

Gray concern number three? A lack of clinical indicators leaves the diagnosis in question vulnerable to denial. How does one document a lack of clinical indicators on a clinical validation query? 

We need to look at the 2019 AHIMA/ACDIS Guidelines for Compliant Query Practices for the answer, which states:

“There is not a required number of clinical indicators that must accompany a query because what is a ‘relevant’ clinical indicator will vary by diagnosis, patient, and clinical scenario… The quality of clinical indicators—how well they relate to the condition being clarified is more important than the quantity of clinical indicators…Clinical indicators can be identified from sources within the entirety of the patient’s health record including emergency services, diagnostic findings, and provider impressions as well as relevant prior visits, if the documentation is clinically pertinent to the present encounter.”

The last obstacle? There are times a provider’s answer could shift the MS-DRG. And more often than not, the DRG shifts downwards, especially when ruling out a previously documented diagnosis. This DRG shift often results in a lower-weighted DRG. And that could result in a negative financial impact for the CDI specialist whom often views this as a negative situation.

In reality, the downgrading of the DRG within the clinical validation process means that the organization would have potentially billed for an incorrect DRG that would likely result in an overpayment or a denial.

CMS and auditors are trained to identify patterns. If a pattern of overbilling is identified, the organization may very well be a prime audit target. Everyone wants to avoid that.

In conclusion, clinical validation involves identifying all evidence within the medical record that supports the fact that a condition exists. It involves finding clinical indicators that may in-fact be normal values not representative of a diagnosed disease. It involves identifying when there may be a lack of clinical indicators present. Lastly, it involves awareness that identifying a condition was ruled out as a result of a clinical validation query is supporting organizational compliance—it can actually help to protect organizations from accusations of false billing patterns and allows the CDI specialist to find success in performing clinical validation reviews and submitting clinical validation queries with confidence.

Editor’s Note: Valdez is a CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.