CDI Coding Diagnosis (not clinically validated)
As a CDI Specialist, are we required to not code a diagnosis that we determined that was not clinically validate AFTER the MD has been queried for clinical validation and continue to support the diagnosis throughout the medical record and/or just on the discharge summary?
Example: Patient is admitted with Sepsis. Patient has Medicaid, Humana, Blue Cross, etc. and does not met Sepsis-3 criteria according to payer. CDI query the MD for more/addition clinical criteria to support this diagnosis based on the payer. MD updates documentation and continues to document diagnosis. However, CDI does not agree or know with the updated documentation that patient is meeting criteria according to the payer's criteria based on pervious denials.
We are told as CDI that we do not have to code the diagnosis and note MM with coder. We know that the coder is required to code the diagnosis if documented in the medical record.
As a discussion, has any one encounter this type of situation and if so, how is this handled at your institution?
Any advice is accepted,