CDI Coding Diagnosis (not clinically validated)

Dear All,

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,




  • If a condition is documented by the provider that is not clinically supported, the CDI team comes in and queries for clinical validation.  If the MD answers the condition is ruled out - the condition would not be coded.

    However, as I believe you mention above, the provider was queried and continued to document the diagnosis that isn't supported after the query response was received. 

    In this case, I would recommend to my team a second query to clarify after discharge and some education to the provider.

  • Thanks for your input.

  • edited December 2019
    There is always a focus on if the CDS "codes" the condition in these situations.  Since the CDS  has no reporting power as far as the codes, it ends up being entirely irrelevant in terms of compliance if the CDS "codes" or "agrees" with the coding or not.  The CDS has no reporting power with CMS (at the vast majority of facilities).   

    For tracking purposes it does matter in terms of retrospective audit, and you should report the clinical truth to your best application of the ACDIS code of ethics. 

    What is important is that you
    1) Initiated a compliant query.   
    2) That the query you did was in fact, in the interest of clinical validation (you can avoid implications of the CDS being implicit in upcoding)
    3) Track patterns of unsubstantiated (potential violations of the requirements of the IPPS) to a physician champion and or committee for further review.....and document having done so in a discoverable location.
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