Clinical Validation: Understanding Why Are Hospitals Vulnerable to Claim Denials?

Is your hospital receiving a high volume of clinical validation denials? If so, you’re not alone.  

Clinical validation denials continue to grow in volume and many organizations remain vulnerable to them. Clinical validation was defined with the 2011 Recovery Auditor (RA) scope of work as a separate process from DRG validation, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. 

Does your organization have a clinical validation process in place, and if so, it is as robust as your DRG validation process? If not, why not?

When Coding Guideline 19 for Code Assignment and Clinical Criteria was introduced, there was a corresponding Coding Clinic that included some key concepts related to how this guideline should be interpreted. These included the following:

1. Although ultimately related to the accuracy of coding, clinical validation is a separate function from the coding process.
2. If the physician documents sepsis, and the coder assigns the code for sepsis, and a clinical validation reviewer later disagrees with the physician’s diagnosis that is a clinical issue but is not a coding error.
3. A facility or payer may require a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but hat is a clinical issue outside of the coding system

So, who in your organization is responsible for clinical validation? It is not a coding function, but has your organization embraced it as a clinical documentation integrity (CDI) function and dedicated the resources necessary to develop a robust clinical validation process?  

I know many organizations have implemented organizational definitions for diagnoses vulnerable to clinical validation like sepsis, acute respiratory failure, malnutrition and others, but organizational definitions are not enough to create a robust clinical validation process.  Ironically, my company often sees clinical validation denials associated with diagnoses that were added through a CDI query at a healthcare organization with organizational definitions. 

You see, it starts with fundamentals. What is the goal of the CDI department? Is it really documentation integrity and accurate reimbursement?  If so, why as a CDI professional don’t we have a defined processes of what to do when a diagnosis isn’t clinically validated but a code is assigned? Is it enough to query to ask if the diagnosis was ruled out? 

There are so many gaps in the clinical validation process on the hospital side that need to be addressed it is no wonder that payers are taking full advantage.