Q&A: Inaccurate clinical validation response

Q: How do you handle a query clinical validation response that remains inaccurate? (i.e., query for sepsis ruled in). Do you capture this?

A: Deciding to ignore a provider’s answer on a query based on our own opinions (whether they are correct or not) is unethical because CDI specialists are not responsible for patient treatment or determining a diagnosis. We also must keep in mind that this is a legal document, attached to the patient. Therefore, if a medical provider deems sepsis is ruled in, then sepsis is ruled in, and should be coded. You have done your job by asking the question in a query format.

We, as CDI specialists, cannot be attached to the outcome of any query, which isn’t always easy. CDI specialists are tasked with reviewing the medical record for accuracy and clarity, ensuring the capture of that patient’s acuity during their hospital stay or clinical visit. When the record isn’t clear, we query the provider. The providers have a legal responsibility to diagnose based on the clinical criteria they deem appropriate.

If there is a lack of evidence that sepsis exists, (or whatever the diagnosis may be), and the provider ignores or disagrees with the query, the case may be escalated to the CDI manager, physician advisor, or other department manager per department policy. If an individual physician consistently ignores or disagrees with CDI queries, then a deeper exploration into the reasons behind his or her responses may be warranted along with additional educational efforts.

Editor’s Note: Dawn Valdez, RN, LNC, CDIP, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at dvaldez@hcpro.com. For information regarding CDI Boot Camps, click here.