- “Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or post-payment claim determination. Clinical validation is performed by a clinician (RN, CMD, or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.”
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.