Clinical Validity

kstewart@capitalhealth.orgkstewart@capitalhealth.org
in CDI Management

We are curious how other systems deal with capturing conditions that are documented but not valid based on the documentation within the record?

  1. Query for clinical validity on all conditions that are documented but not clinically valid
  2. If not valid, it is not captured even if documented
  3. Reported solely based on documentation without a query

Thank you in advance for your input!

Comments

  • lprescott1lprescott1

    At ACDIS we encourage the use of clinical validation queries.

  • delp10290delp10290

    We are in the process of writing a clinical validation policy. Does anyone have a policy that they would be willing to share with us?

  • mary.mastrandreamary.mastrandrea

    We send out clinical validation queries for documented diagnoses without clinical support. If no further clinical evidence is given by the provider, but is still documented the case is escalated to the CMO for a peer to peer discussion, result of which is documented in our CDI software.

    Diagnoses without clinical support are not coded.

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