Clinical Validation Reviews for CDI Professionals

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Clinical Validation Reviews for CDI Professionals

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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


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


The False Claims Act (FCA)

Appealing Clinical Validation Denials

Crafting the Validation Appeal

Chapter 3: Compliant Query Practices

Agency Query Advice



Clinical indicators

Query Formats

Verbal queries

Written queries

Reasons for Queries

Chapter 4: Common Validation Susceptibilities

Quality Considerations

Value-Based Purchasing


Denials and Clinical Standards

Clinical Validation Case Studies


Postoperative Pulmonary Insufficiency



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)


                Review Rates

                Query Rates


                Reconciliation Metrics


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



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.