Clinical Validity

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?

Thank you,

Nicole Copper, BSN, RN, CCDS

Comments

  • Hi Nicole, we complete clinical validation queries concurrently and not retrospectively. While we do not have a policy regarding this, it is something the clinical documentation nurse does on all cases in addition to having verbal conversations with providers when possible.

    I also have a workque built within our EMR that allows me to review specific DRG cases where we have historically fallen out. I started this in 2020 and worked with our coding team to ensure we are getting sepsis right. The volume of cases that did not have indicators has greatly reduced. If you have any questions, feel free to email me at jcjohnson@premierhealth.com


    Kind Regards,

    Jeanne

  • Hi Nicole,

    Is this in the inpatient or outpatient setting? I cannot speak to the inpatient setting (as Jeanne did above).

    In the outpatient setting it is a little difficult to work concurrently with ambulatory encounters. Generally, the EMR is reviewed a few days prior to a patient's scheduled visit for opportunity (outstanding or missed chronic conditions from prior 2 calendar years, medications without indication, etc.) a query can be sent up to the day prior to the visit requesting clarification, specificity, or indication of findings. Best practice is to encourage the provider to "respond," if applicable, in the next visit's documentation. The CDS follows up after the encounter to review the provider's "response" in the documentation.

    Should further clarification be needed after the visit, the CDS should follow up via the organization's established practice (new written or verbal query) requesting the provider addend the note if within the established time frame for submission.

    Amy Campbell, RN, MSM, CCDS-O

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