Q&A: Clinical validation queries

Q: How can we help providers understand that clinical validation queries aren’t meant to question their medical decision making? 

A:  To avoid physicians feeling like the CDI team is questioning their medical decision making, the CDI specialists should introduce the concept and purpose of clinical validation to the medical staff. The education should stress that we not challenging their medical judgement but are challenging the quality of the documentation, meaning we are only reviewing the documentation (not assessing the patient) and support for the documented diagnosis is not clearly evident.

The provider should understand the purpose of a clinical validation query is to point out that the documentation does not offer clinical support and allows the provider to further clarify the patient’s diagnoses. This further clarification allows for accurate code assignment and accurate reporting of the conditions present.

Provider’s should be educated as to how to respond to such queries. For example if after review the provider concludes that the diagnosis is not present, a statement should be added to the record stating the condition has been ruled out upon further consideration. Or if the provider concludes a condition is present the documentation should offer the support as to why. Such support may include a statement that describes why the patient is presenting atypically, or why the treatment plan is different than the norm.

Providers can avoid receiving clinical validation queries if they follow the stated diagnosis with the words “as demonstrated by” then list the clinical evidence and then end with the words “with a treatment plan of…” Such complete documentation demonstrates the clinical support for the diagnosis and provides support for reportability.

Providers should also be involved defending denials when you are in the appeals process. They would better understand when they are being challenged, what records are vulnerable to challenge a begin to apply stronger documentation.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, click here.