Clinical Validation Denials - HELP!!

Hi, everyone. I know we have talked about this excessively it seems but we are experiencing a high number of denials regarding clinical validity of a diagnosis.  Our coding department has been advised to follow the "provider documented the diagnosis so you must code it" rule.  CDI is advising that the diagnosis cannot be clinically validated, have queried the providers (most of whom are free standing providers and not employed by us) without much luck to provide clinical indicators/treatment to support the diagnosis.  And the denials have started rolling in as we warned.  Our coding manager wants to make it policy that if the account is reviewed by one of the CDI RN's and the diagnosis is not clinically supported (even if we enroll our CMO to help with this process) that we not code it.  But....I thought I had read somewhere that it has been advised facilities could not make an internal policy regarding this issue?  Am I wrong?  I can't seem to find it anywhere.  Any suggestions?  We don't have a "denial department" and that is part of the issue as well.

Thanks for everyone's input in advance.



  • Hi April,

    I know you have probably already seen the ACDIS white paper regarding this issue but I'm attaching it in case you haven't. Clinical Validation paper.pdf

    Guideline 19 tells us that code assignment is not based on clinical criteria used by the Provider and that code assignment must be based on Provider documentation. We are not allowed to choose to code or not to code if not clinically supported by our standards. I think you'd be best served to query for clinical validity. If the Provider stands behind the diagnosis and that chart is denied then that issue has now become a Provider issue and is not a CDI or Coding issue at that point. You have done your due diligence to verify that the condition truly exists and/or asked for additional clinical indicators.

    I, personally, would advise against an internal policy such as the one that's been suggested to you.



  • AHA Coding Clinic Information

    Coding clinic 4th Quarter, FY 17 pg 110


    ·         Question:

    o    “A facility may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis” Would it be appropriate for facilities to develop a policy to omit a diagnosis code based on the provider’s documentation not meeting established criteria?

    ·         Answer:

    o    No. It is not appropriate to develop internal policies to omit codes automatically when the documentation does not meet a particular clinical definition or diagnostic criteria.  Facilities may review documentation to clinically validate diagnosis and develop policies for questioning the provider for clarification to confirm a diagnosis that may not meet particular criteria.

  • Aha!  That's the one I was referring to but thought it was older!  Thank you so much nloshaw! 
  • edited March 13

    All we can do is query.  If the physician doubles down on the diagnosis it  has to be reported by the coder.  

    The rest of the matter will have to be up to the physician advisor and administration to handle.  I recommend you track those queries in case you are called to present what has occurred (To administration or to a committee) and what you did as a group and as an individual CDI to intervene where validity might be in question by an auditor.

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