What is the purpose of Clinical Validation?
Sounds like a trick question right?
Well no. It is a question every CDI program should ask and re-evaluate to make sure the purpose of these queries is actually to validate a diagnosis based on specific criteria.
One of the popular saying I hear so often is if the diagnosis is ONLY documented once, go ahead and place a query to validate the diagnosis.
Ok, I can do that but what if the clinical indicators are not there and the provider still confirms the diagnosis, does this mean I validated the diagnosis?
I don’t think so because the purpose of initiating the query was because the medical record lacked indicators to support the diagnosis NOT because it was documented ONCE in the chart. I had a conversation with a longtime friend that works as an auditor for a well-known insurance company about this topic and she confirmed “whether the doctor writes the diagnosis once or ten times, if the indicators are not there that DRG can still be downgraded”
We should validate a diagnosis not because it was documented ONCE, but because the indicators are not present. I know we don’t want to EVER question a physician’s medical decision making, but we can escalate this to a physician advisor for a second look if necessary.
As for me, when I decide to write a clinical validation query, it is to validate the actual diagnosis not the amount of time documented in the chart.