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.