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. 


  • Agree 100%.  Something such as acute respiratory failure may be noted 'only once' in the ED record, yet be clearly and strongly supported by acknowledged clinical indicators.  The ARF may not be noted hours later by the admitting MD because it is resolving as a result of aggressive and prolonged treatment in the ED before the patient is sent to the floor..but, this does not mean it can't be coded.

    Conversely, a condition may be noted many times, yet fail to meet accepted clinical criteria, and may need to be confirmed by CDI.    The issue is the quality of the documentation rather than the quantity.

    Paul Evans, RHIA, CCDS

  • Wow! No we did not see the patient, but isn't part of the purpose of documentation to paint the picture? 

     All the rhetoric is entertaining, but in the end hospitals are having to fight tooth and nail for revenue that is threatened to be taken away by argument of poor documentation. Everyone (auditors) is not "playing" by the same rules (coding clinics, guidelines, etc.)

    We as CDIs have the duty to educate ourselves and continue to carry out our job to "achieve complete and accurate documentation in the medical record in a way that can be translated into precise ICD-10 coding and more accurate DRG assignment" (2017 CDI Pocket Guide Introduction).

     CDIs that are performing poorly need to be weeded out by their superiors so that the integrity of the organization can be maintained.

  • yaya20,

    I am concerned about the tone of your statements.

    When a doctor documents a diagnosis, the only person responsible for the diagnosis is the provider, not the CDI and certainly not the coder. Lets not take this job too seriously. Whether you place your little query or not, no one dies. 

    4) As CDIs, we need to used our common sense. You didn't see the patient! Questioning a doctor's diagnosis from the basement of the hospital or 3000 miles way (for remote CDIs) is just unprofessional and very annoying. In my experience, most CDIs do not take the time to educate themselves on a topic before rushing to conclusion. 

    I agree the provider is responsible for the diagnosis, but as kwilliams commented above, the payers are challenging those diagnoses when their list of criteria is not met.  If the record is unclear, it is important to proactively query for additional documentation of clinical decision-making to support the chosen diagnosis.  It is not questioning the diagnosis.

    Jeanne McCorkle, BSN, RN, CCDS

  • I'd urge anyone so inclined to read the article ACDIS just released on the complicated topic of Clinical Validation. I think this paper is very comprehensive and presents a fair and balanced overview.   I agree with Jeanne that there is definitely a role for CDI in regards to proactively working with the physicians to ensure the integrity of the record.    Ultimately,  I think clinical validation may often require peer-to-peer reviews, such as MD to MD.   This does not negate the role of the initial review performed by a CDI using vetted criteria accepted by the Medical Staff.



    Clinical validation and the role of the CDI professional

  • I agree @ jmccorkl... the tone of the response is concerning for me as well. Yaya20, seem like you know me personally because you referred to me at "Matthew".

    I am always open to having dialogue about ways to move our industry forward. Having passionate discussions about documentation improvement is always a positive. Great comments!
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