Unfortunately, many in the industry took the assertion that “clinical validation is performed by a clinician (RN, CMD or therapist)” out of context. This was referencing RAC processes and who they have identified to perform clinical validation. It is up to every organization to create their own policy and procedure related to clinical validation. In reality, clinical validation is a multi-tiered process, and a piece of it is already being performed by CDI professionals with all different types of backgrounds.
CDI professionals should be reviewing clinical indicators to identify documentation gaps and/or discrepancies requiring clarification. But in the end, clinical validation should be performed in peer-to-peer fashion. As CDI professionals, we are not part of the clinical team, but are the liaisons between the clinical and coding worlds; as a result, we do not perform as a “peer” when issuing clinical validation queries. CDI professionals are trained on the job, regardless of their background, education, and credentials, to understand evidence-based definitions, rules, and regulations related to coding and industry standards so that these can be incorporated into their review process.
Final clinical validation requires provider-to- provider review. Since many providers do not understand the complexity of coding and documentation, it is very important for CDI professionals to become experts in both coding and clinical reviews. It is your knowledge that qualifies you as a clinical validator, not your credentials as a HIM coding professional or your credentials as a clinician.
This week, as we continue to explore querying for acute (metabolic or toxic) encephalopathy, I want to examine the Glasgow Coma Scale (GCS) as a
A few weeks ago, I shared some information about Risk Adjustment Data Validation (RADV) coding audits. I mentioned the increased number of audits, and the
Please log in to your account to comment on this article.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
