RE: [EXTERNAL] Question Regarding Criteria and Clinical Judgment

As long as the provider can document the justification for his clinical
decision then their decision stands. In the past when I've had these
issues I've had a provider to provider discussion between the insurance
company physician and our diagnosing physician. I've found that very
few physicians who haven't seen the patient are willing to override the
decision of the provider at the bedside.



And remember to, as CDI's we are not to question the providers clinical
decisions, just ask for documentation to better support those decisions.



Robert



Robert S. Hodges MSN, BSN, RN, CCDS, VHA-CM

Clinical Documentation Improvement Specialist

Secretary, Nursing Professional Standards Board

Aleda E. Lutz VA Medical Center

1500 Weiss Street, ATTN PAS-136

Saginaw MI 48602



989-497-2500 x13101

Robert.Hodges2@va.gov





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"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens
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