Understanding the Importance of Clinical Validation Queries

Clinical validation queries have been recommended for almost a decade, yet many clinical documentation integrity (CDI) and coding professionals continue to struggle with crafting these types of queries.

The Guidelines for Achieving a Compliant Query Practice (2022) states, “Queries may be necessary in (but not limited to) the following instances: To seek clarification when it appears a documented diagnosis is not clinically supported or conflicting with the medical record documentation (clinical validation).” Another reason to query is “to determine if a diagnosis is ruled in or out.”

As defined in Clinical Validation: The Next Level of CDI (2023), a practice brief from the American Health Information Management Association (AHIMA), “the clinical validation process involves a clinical review of the health record to identify potential gaps between documented diagnoses and the corresponding clinical evidence.”

Although clinical validation queries were initially referenced in the 2011 Recovery Audit Contractor (RAC) scope of work, it was not within scope when current RAC contracts were awarded. The Centers for Medicare & Medicaid Services (CMS) opened the door to clinical validation, but private payers have embraced it and continue to push the boundaries by adding a new type of denial, removing clinically valid documented diagnoses added through what the payer considers non-compliant queries.

Clinical validation appeals are so difficult because there is limited agreement among medical providers about how to diagnose many conditions. There is not often a one-size-fits-all solution in medicine. Each patient is unique, and historically, most medical criteria were established using a homogenous population, so many patients will have an atypical presentation.

Due to this lack of industry consensus, payers often use more stringent criteria compared to bedside providers, and there is limited transparency into payer clinical validation criteria. As patients, we want our healthcare provider to aggressively diagnose and treat us to prevent poor outcomes, but payers want to deal in absolutes.

Unfortunately, there are no industry screening criteria like MGC or InterQual, which is available to help guide inpatient medical necessity decisions, another type of payer denial. Many hospital professionals rely upon CDI pocket guides or organizational definitions to protect the hospital from clinical validation denials, but they only serve to promote consistency among hospital departments. There is currently no requirement for payers to adhere to these.

Clinical validation queries are necessary to remove a reportable diagnosis (based upon the ICD-10-CM Official Guidelines for Coding and Reporting) that is at risk for clinical validation denial. Additionally, these guidelines state:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. If there is conflicting medical record documentation, query the provider.”

The American Hospital Association (AHA) Coding Clinic clarified the intent of this guideline in the Fourth Quarter of its 2016 edition:

“While physicians may use a particular clinical definition or set of clinical criteria to establish a diagnosis, the code is based on his/her documentation, not on a particular clinical definition or criteria . . . For example, 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 it is not a coding error.” 

In other words, a clinical validation query is necessary to rule out a reportable diagnosis that lacks clinical evidence to avoid it being reported within claims data. In turn, clinical validation queries can prevent future clinical validation denials.

Generally, as the volume of queries increase, there should be a corresponding increase in the volume of clinical validation queries specifically. Yet, clinical validation queries continue to comprise a small percentage of queries at most organizations.

It is much more efficient and cost-effective for a clinical validation query to occur concurrently than to appeal a clinical validation denial. The back-end processes needed to correlate, review, and appeal denials is a hidden administrative cost at many hospitals. According to the AHA, administrative costs associated with payer denials account for more than 40 percent of total expenses.

When evaluating the effectiveness of CDI efforts, it would be beneficial to track cases with clinical validation denials to see if they were reviewed by CDI staff, and if so, to determine whether the CDI staff missed an opportunity to issue a clinical validation query. Ironically, clinical validation denials often result from a CDI query when the CDI professional had minimal clinical evidence for the requested diagnosis. This is where organizational definitions matter, particularly pertaining to promoting and validating consistent criteria before querying to add a diagnosis to the health record.

These same definitions can be used to validate documented diagnoses that impact the MS-DRG assignment, including the principal diagnosis. Tracking clinical validation denials and linking them back to CDI efforts is a great educational opportunity to help CDI staff understand the importance of clinical validation.

Additionally, emphasizing the importance of clinical validation within the CDI workflow can help minimize revenue leakage through decreased denials and lowered administrative costs.

Programming note:

Listen to senior healthcare consultant Cheryl Ericson report this story live today during Talk Ten Tuesday with Chuck Buck and Angela Comfort, 10 Eastern.