Q&A: Clinical indicator contradictions

August 27, 2020

CDI Strategies - Volume 14, Issue 35

Q: I am looking for clarification on two seemingly contradictory statements. One says when a practitioner documents a diagnosis that does not seem supported by clinical indicators a query should be raised. However, the other states that a provider's statement that a particular condition is present is sufficient and code assignment is not based on clinical criteria used by provider to establish a diagnosis. Can you provide any additional thought processes or commentary?

A: Think of these statements as different rules applying to different pieces of the CDI and coding process. I’m going to divide them up in an effort to demonstrate the tasks needed.

First, let’s talk about the code assignment of a diagnosis, then we will talk about the medical component that goes into the decision-making process of a provider determining a diagnosis.

For code assignment, the Official Guidelines for Coding and Reporting state under section 1.A. 19:

“Code assignment and Clinical Criteria- The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

So, for code assignment, the fact that a provider documents a diagnosis allows for code assignment if the diagnosis in question meets the requirements of a principle and/or secondary diagnosis.

Now, let’s move over to what goes into the provider determining a diagnosis. The provider uses clinical indicators as part of the process to determine if a patient has a specific condition. There are numerous “medically accepted standards” for clinical indicators for most diagnoses, however, a provider can determine the diagnosis by any clinical indication that he/she feels is present and represents a condition in the patient.

In other words, if a patient is diagnosed with acute heart failure, there should be “certain clinical indications” in the documentation that support the patient is in the acute phase of heart failure versus the chronic phase of heart failure or having no signs of congestive heart failure at all.

Clinical validation is a regulatory requirement under the False Claims Act as diagnoses that are billed to Medicare/Medicaid for payment “must be clinically valid.” This is why we have to ensure that the diagnoses are clinically supported.

If there is not a clear picture of clinical indicators in the documentation to support the diagnosis, a clinical validation query should be generated. This allows the provider to state what criteria was used in determining the diagnosis in effort to help support or “validate” the diagnosis or the provider may have forgotten to rule the diagnosis out after study and the clinical validation query offers the provider that opportunity.

What is not regulated in regard to clinical validation is what staff performs the clinical validation process. Some facilities may prefer to have both CDI and coding perform clinical validation reviews and submit queries; other facilities may prefer to have only one of the two departments handle these tasks.

For additional information on clinical validation, consider reviewing the following materials:

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.

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