Are any facilities performing retrospective queries based on clinical validity? This is something we are looking to institute in our practice to help clarify diagnoses that have no documentation of support in the medical record. We feel it is best practice to only report validated diagnoses and this seems to be a focus of denials currently.
If you do perform retrospective queries who initiates the query? CDI or Coding?
If you do perform clinical validation would you be willing to share the process or policy that has been put into place?
Nicole Copper, BSN, RN, CCDS