Clinical validation queries

Currently, when we ask clinical validation queries, we do not take a financial impact. We only reconcile as "agreed and documented". Our vendor tells us that some facilities are taking a positive financial impact if they are successful in getting the supporting clinical evidence into the record. They are not addressing an impact of any kind if they are unable to get the documentation to support the diagnosis. We are struggling with how to handle these and would like to know how others address this. Our thought is that, if the diagnosis is documented, the coders are going to code it, so is it right for us to take a financial impact? We feel our role is trying to prevent a DRG downgrade by the payer and we haven't figured out a way to take "credit" for preventing a denial.



  • I agree based on coding guidelines the documentation of the dx by the clinician should be captured and reported with understanding that it meets the principal or secondary dx criteria set forth. The initiative of a clinical validity query is a defensive approach to avoid denial during audits. With this understanding it would be a fine line to attribute financial impact. Our facility is able to capture impact during query finalization of the Primary and Secondary Impact and have identified Primary impact as Clinical Validity:

    and Secondary Impact to further identify support of the dx resulted Clinician Education to assure documentation integrity to support the dx:

    This approach allows for data extraction to attribute the impact with detail regarding assurance of the clinical validity that can identify clinician education opportunities as they relate to clinical validity and query quantity.

    Hope this is helpful 😀

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