Potential clinical validation resource

ACDIS is currently playing with the idea of putting together a book on the subject of clinical validation and we want YOUR opinion! If you have a moment, would you mind answering the questions below?
  1. Do you think this resource would be valuable for CDI? Why or why not?
  2. What would you like to see included in the book?
  3. Would you also purchase an online learning course on this topic to augment your staff training?
We appreciate your input!  :)


  • I just had a consultant tell me I should not query for clinical validity. If MD wrote diagnosis we should code it. If patient had one pulse oxy of 70 % no physical findings of tachypnea, no accessory muscle use and on usual home oxygen 2 liters  should not question the diagnosis of acute respiratory failure. A published book or resource would bring credibility to what we are trying to do as CDI
  • I don't want to have too heavy a hand here but the reality is that this is required for compliance, period.

    The AHIMA Practice Brief states that when a provider documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, a query should be generated. (2013 and 2016 versions).   The AHIMA standards of ethical coding require that only accurate and valid codes be reported.   Coding clinic states that if the attending physician affirms that a patient has a condition despite certain clinical parameters not being met, the facility should request the physician document the clinical rationale and be prepared to defend the condition if audited. (Coding Clinic 4th Q 2017 pg. 110).  The Official Coding guidelines published by CMS states that the UHDDS defines the attending provider as the clinician of record at the time of discharge and goes on to state that the list of diagnoses in the patient record is the responsibility of the attending provider.  Coding Clinic 3rd Q 2016 p. 26 states that it is the responsibility of the attending physician to gather and collate ALL (not some) of the findings from the consultants and other providers involved in the care of the patient and that the plan of care is based on the attending physician’s evaluation, interpretation and collation of ALL (not some) of the findings (path, radiology and lab).  (I assume here they mean the abnormal findings as one would not expect much documentation about normal findings.)    Mind you these are official cooperating parties which legally set the rules and standards for coding and billing.  

    The physician signed a condition of participation with CMS and the false claims act has an exhaustive legal explanation of the requirements that any billing done with the US gov. requires accurate and precise delivery of goods with zero tolerance of incorrect billing practices which in theory includes both under and over billing.   You are liable for a false claim if you knowingly make a false claim, false record or false statement to get a claim made.  If you have actual knowledge, deliberate ignorance of the truth or reckless disregard of the truth you also liable. 

    An argument could easily be constructed where diagnosis reported without clinical indicators that the legal definition of the above is being met.  You could also construct a similar argument when a provider refuses to provide a diagnosis that is clearly present (albeit, you would need a review and verification by another licensed physician in either direction for final ruling).  Reference: https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf

    The physician may feel they aren’t really held legally accountable for that due to the difficulties of diagnostic medicine, but unfortunately for the provider (and everyone else involved), the facility at which the patient receives the care IS being held to that legal standard.

    From the perspective of a facility employee it seems clear what the legal requirement of a CDI is in this regard.   This is about compliance not role creep.  Be that as it may, it would probably be best practice to funnel the above information through your physician advisor and legal/compliance departments rather than taking on the physician directly in a battle.

  • Hello larchibald,

    1. Yes and no. CDI role in clinical validation *i think* plays an important collaborative role with UM and CM which some facilities and states based on contract agreement with payors have various clinical criteria for diagnoses. It may or may not be a helpful resource as I am finding providers have different clinical perspectives to treatments and guidelines of treatments that it may be confusing for the CDS to follow or contribute to a one source. One example we are having some challenges are with the diagnosis of Sepsis, severe sepsis, SIRS. We as a facility are trying to pinpoint what providers are using as criteria, and what some of our payors are accepting as a diagnosis and treatment which are now returning to us as a highly denied diagnosis on a claim. Questions that are popping up are - what criteria is everyone using? Why am I having to order xyz labs, etc and why so often? 

    2. Thank you afrady for your explanation. I will certainly use these references to remind and construct for my team a method of teaching providers that again we are bound by CMS to code and AHIMA to query as needed and as appropriate. If a text like this is developed, having resources throughout what afrady shared in previous thread will be of help. 

    3. Perhaps, if the content included most common clinical validation diagnoses and example query formats or examples of those treatments. 

    Thank you! 
    Peter Gampon, RN
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