The importance of clinical validation has increased for obvious reasons. With the implementation of electronic medical records (EMRs), hospital and health systems are moving forward with clinical documentation improvement. EMRs have their benefits, but sometimes there are inconsistencies found due to a chronic problem in the provider community: to copy and paste from a previous encounter.
How errors impact payers and patients
Payers have used clinical validation to deny claims and the numbers have increased post ICD-10. A frequent error found is in patients on chemotherapy. A common side effect in a patient on chemotherapy is pancytopenia, a major comorbid condition (MCC) reflecting a higher severity of illness that requires clinical intervention and resource utilization. A patient might have a history of the condition being on the chemotherapy. The documentation might appear in the chart from a previous encounter when there are no clinical or lab findings supporting it during the current encounter.
As a coding professional, clinical validation can be complicated and technically very hard to judge. According to official guidelines for coding and reporting, if the diagnosis is in the medical record, it should be coded without any validation requirement. This exposes the chart to be audited and subsequently denied, especially if it is only the MCC that is driving it to a higher paying diagnosis-related group (DRG) or severity of illness (SOI).
How do hospitals avoid this ongoing issue?
The quick answer is to incorporate a post discharge, pre-bill clinical validation system that goes beyond a traditional DRG validation process. Clinical validation requires an extensive audit of the diagnoses that can be substantiated based on clinical criteria authenticated by reputable medical literature and journals.
Who should be involved in the process?
A seasoned clinician who has the knowledge or help from a coding guideline perspective is an ideal combination to develop a validation process. Depending on the complexity of the case, the review can be focused towards certain DRGs, mortality and quality cases.
What is the key to success?
This clinical validation process will affect the hospital’s DNFB (discharged not final billed) list. Buy-in from C-suite leadership is required to make this a successful venture. The clinical leader is an important player, as her engagement with the medical staff will be critical to obtain the desired results.
Why is this important?
By combining the skills of a clinician and coding professional, the clinical validation process can improve appropriate capture of accurate documentation which can reflect the true clinical picture and severity of illness. Conquering the pre-bill validation process will decrease denials and improve overall revenue integrity. It’s time to fight the payers by using their own method and subsequently bridge the gap between coding and CDI departments.
