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.
As Clinical Documentation Integrity (CDI) departments transition from a revenue enhancement tool to a revenue integrity tool, the industry needs to rethink query metrics. Do
In the first three parts of this series, we explored how payers analyze claims data, identify cases for additional scrutiny, and interpret the medical record
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