Q&A: Clinical validation queries and financial impact

Q: Currently, when we ask clinical validation queries, we do not take a financial impact into account. We only reconcile as "agreed and documented." Our vendor tells us that some facilities are taking a positive financial impact if they are successful in getting the supporting clinical evidence into the record. They are not addressing an impact of any kind if they are unable to get the documentation to support the diagnosis. We are struggling with how to handle these and would like to know how others address this. Our thought is that, if the diagnosis is documented, the coders are going to code it, so is it right for us to take credit for having a financial impact? We feel our role is trying to prevent a DRG downgrade by the payer and we haven't figured out a way to take "credit" for preventing a denial.

A: Clinical validation queries can be a defensive approach to avoid denials. With this understanding, it becomes a fine line whether or not to attribute financial impact.

 Look into creating an internal guideline that addresses the how your organization will quantify outcomes related to clinical validation query efforts.

For example, you may define clinical validity as meaning “a query sent for the purposes of clinical validation in a situation where a diagnosis is documented, though it lacks the clinical indicators and support required to substantiate the diagnosis.” If the primary reason for a clinical validation query is to substantiate the principal or secondary diagnoses, there may very well be a related correlation between the resulting documentation and the final DRG assignment. If additional documentation supporting the diagnosis is added, it may ensure a DRG. If additional supportive documentation is not added and/or the query results in a diagnosis being removed, it could lessen the DRG weight.

Many organizations leverage clinical validation queries for both DRG assurance and for educational purposes.

Track your clinical validation queries. While this may result in a loss of revenue when there are not clinical indicators present to support the diagnosis, the validation is sent to ensure the medical record is accurate. Work with your IT department or software vendor to see if you can look into which diagnoses are requiring clinical validation and if it is even possible to narrow that down to the provider. This information can be compared against the DRG downgrades you receive and are unable to appeal. And that can be leveraged for additional educational outreach to a provider group or directly to an individual provider if necessary.

Editor’s note: This question and answer were adapted from a thread on the ACDIS Forum. To learn more about participating on the Forum, click here.