Clinical Validation Reviews for CDI Professionals
Clinical Validation Reviews for CDI Professionals tackles the nuances of a critical concern for CDI professionals and provides expert guidance for meeting challenging chart reviews head-on.
With government auditors frequently denying claims due to lack of clinical indicators for documented diagnoses, CDI professionals are left asking whether they should simply code a clinically unsupported diagnosis or query the physician. While the answer may seem clear, querying can lead to productivity reductions, additional education outreach, and a call for broader policies governing query escalation and reconciliation.
This brand-new book leverages its authors’ expertise to help CDI professionals effectively and efficiently navigate these issues during a necessary query process. By understanding clinical validation concerns, CDI staff can become better translators and storytellers—clarifying the medical record without appearing to question the physician’s medical judgment.
In this book, readers will learn how to:
- Develop a clinical validation record review process
- Research and develop hospital- or facility-specific clinical criteria for high-volume diagnoses such as sepsis, congestive heart failure, and malnutrition
- Apply recent recommendations from the Association of Clinical Documentation Improvement Specialists and the American Health Information Management Association related to compliant query practice and clinical validation efforts
- Collaborate with various departments to develop effective clinical validation processes
- Conduct successful physician education related to clinical validation
Click here to access chapter previews.
Published: March 2019
Page count: 164
ISBN: 978-1-68308-840-0
Table of Contents
About the Authors
Introduction
Chapter 1: Core Responsibilities and Query Progression
Program Development
Progression of Responsibilities
Emergence of Clinical Validation Practices
Ethical Practices
Chapter 2: Government Oversight and Validation Efforts for Denials Management
Claims Denials
CMS Medical Reviews
Contractor Review Tools
Government Investigations and Takebacks
OIG
The False Claims Act (FCA)
Appealing Clinical Validation Denials
Crafting the Validation Appeal
Chapter 3: Compliant Query Practices
Agency Query Advice
Definitions
Ownership
Clinical indicators
Query Formats
Verbal queries
Written queries
Reasons for Queries
Chapter 4: Common Validation Susceptibilities
Quality Considerations
Value-Based Purchasing
Sepsis
Denials and Clinical Standards
Clinical Validation Case Studies
RespiratoryFailure
Postoperative Pulmonary Insufficiency
Malnutrition
Encephalopathy
Acute Kidney Injury
Chapter 5: Enlisting Assistance From Physicians
Physician Advisor
Physician Champion
Clinical Validation Rollout
Educational Efforts
Verbal Interactions
Validation Assistance
Chapter 6: Effective Metrics for Programmatic Clinical Validation Measurements
Key Performance Indicators
Validation Variances (Coverage)
Productivity/Efficiency
Review Rates
Query Rates
PhysicianResponse
Reconciliation Metrics
Performance
Appendix A: Guidelines for Achieving a Compliant Query Practice, excerpt
Who Should Follow This Brief?
Why Query?
Clinical Indicators
Appendix B: Clinical Validation and the Role of the CDI Professional, excerpt
The Case for Clinical Validation
Appendix C: Sample Clinical Validation Job Descriptions
CDI Specialist Job Description
CDI Clinical Validator Job Description
Physician Advisor Job Description
Appendix D: Sample Clinical Validation Query Policy
Appendix E: Clinical Validation Case Scenarios
Clinical and Documentation Considerations
Head Injury or Diabetes-Related Illness?
Stroke or Language Barrier?
Altered Mental Status or Overdose?
Chronic Obstructive Pulmonary Disease (COPD) or Respiratory Failure?
Malnutrition or Low Body Mass Index?
Hypertension or Kidney Disease?
Surgical Complication or Unavoidable Outcome?
Dementia or UTI?
Additional Sample Queries
Encephalopathy
Sepsis
Respiratory Failure
Kidney Injury
Acute Blood Loss Anemia
Appendix F: Resources
About the Authors
Cheryl Ericson, RN, MS, CCDS, CDIP, is manager of clinical documentation services for DHG Healthcare in Charleston, South Carolina. The program at DHG expands out of Medicare severity diagnosis-related group (MS-DRG) assignment into quality concerns. Its focus on clinical clarity and complete diagnosis coding prepares CDI programs for accurate outcome measures and reimbursement under all payment models. Ericson is a CDI subject matter expert for a variety of industry publications and associations and keeps regular speaking engagements. She served as a chair of the CDI Practice Guidelines Committee for ACDIS and has served on its advisory board, as well as on the Certified Clinical Documentation Specialist (CCDS) credentialing committee.
Cathy Farraher, RN, MBA, CCM, CCDS, is a care manager at UC San Diego Health in California and previously served as a CDI specialist for Newton-Wellesley Hospital in Newton, Massachusetts. She has experience as an ICU nurse and nurse consultant in case management and has served as a legal nurse consultant, a utilization review nurse, and an off-shift supervisor at a Level I trauma center in Boston. Farraher was a cochair for the CDI Practice Guidelines Committee for ACDIS and a co-leader for the Massachusetts ACDIS local chapter.