Q&A: Clinical validation

Q: What is the meaning of the addition to the 2017 Official Guidelines for Coding and Reporting related to clinical validation? The new statement reads:

“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.”

A: I was very happy to see this statement, as I felt it reinforces exactly what we teach in our boot camps and our publications. The confusion lies in the understanding that clinical validation is different from code assignment.

As the new direction states, code assignment is not based on clinical criteria—it is based on the provider’s statement that a diagnosis is present. When the Recovery Auditors started reviewing clinical validation, many organizations changed their practices to avoid denials. They chose not to code specific diagnoses, even if they were stated by the provider, because they felt the diagnosis was not present. This practice concerned me, as we as coders and CDI specialists are not caring for the patient, but are merely reviewing the record. Just as we can only add a diagnosis to a claim if documented by the provider, we should never remove a diagnosis from a claim because we disagree with the provider.

That said, we do have an obligation to work with our physicians to assure the diagnoses documented are clinically supported within the record. Thus, we will continue to ask clinical validation queries when we feel a diagnosis is not supported. This practice is simply clarifying if a diagnosis is present and encouraging providers to clearly state a diagnosis and indicate how that diagnosis was determined. We will still be challenged by auditors related to the validity of a diagnosis.

The new guidance is simply telling us that even if there is no support within the record, we must assign the appropriate codes as supported by the documentation.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, is the CDI Education Director at HCPro in Middleton, Massachusetts. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit http://hcmarketplace.com/clinical-doc-improvement-boot-camp-1.