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Guest Post, Part 2: Where do we stand with clinical validation?

clinical validation poll(1)

According to an ACDIS poll, 70% conduct clinical validation reviews.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

At the 2017 ACDIS conference in May, Nelly Leon Chisen, RHIA, director of coding and classification, the executive editor of the American Hospital Association’s (AHA) Coding Clinic provided clarification on the new Official Guidelines for Coding and Reporting, I.A.19 titled “Code Assignment and Clinical Criteria.” (Read last week’s post here.) At the meeting, Nelly explained the Guidelines intended to reaffirm long-standing advice that coding must be based on provider documentation, essentially that:

  • Only the physician, or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis, can “diagnose” the patient.
  • Clinical information published in Coding Clinic does not constitute clinical criteria for establishing a diagnosis, substitute for the provider’s clinical judgement, or eliminate the need for provider documentation regarding the clinical significance of a patient’s medical condition.

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Guest Post, Part 1: Where do we stand with clinical validation?

clinical validation queries

According to a recent survey, 44.88% send 5 or more clinical validation queries monthly.

By Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS

The 2017 Official Guidelines for Coding and Reporting, effective October 1, 2016, contained a new, perplexing, and problematic section I.A.19 titled “Code Assignment and Clinical Criteria,” which states:

“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.”

This has been incorrectly interpreted by some to mean that clinical validation of documented conditions is no longer required for code assignment on claims.

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Note from the Associate Director: Announcing a new outpatient version of the CDI Pocket Guide

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Associate Director Rebecca Hendren

By Rebecca Hendren

Outpatient CDI is a fast-growing area of the profession. So, I’m excited to announce a new resource that will be an incredibly useful tool for those expanding to the outpatient arena. Richard Pinson, MD, FACP, CCS, and Cynthia Tang, RHIA, CCS, authors of the CDI Pocket Guide, are currently finishing their work on a new version focused on Hierarchical Condition Categories (HCC): the 2018 Outpatient CDI Pocket Guide!

One of our guiding principles at ACDIS is to be at the forefront of changes in the industry. We want to provide our members with guidance, information, and resources they can turn to for education and clarification as they venture into new CDI focus areas. We’ve been publishing articles exploring the growing outpatient and ambulatory arena for several years now and will continue to do so as this segment of the profession grows and changes. We want to keep our fingers on the pulse of what’s going on and share that knowledge with our members.

We bring together leading thinkers in the profession who can share their expertise, whether through articles in the CDI Journal, innovative sessions at our annual conference or the new outpatient-focused ACDIS Symposium, or lively discussions in the ACDIS Forum.

I’m delighted that the trusted authors of the CDI Pocket Guide are equally forward thinking and partnered with us to develop a this new resource.

Please continue to let us know what information you need and what resources you would like ACDIS to offer. We really do listen to you and use your feedback to develop our editorial directions.

Editor’s note: Hendren is the associate director of membership and product development at ACDIS. Contact her at rhendren@acdis.org.

Make the CDI Pocket Guide Even Better 

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The 2015 CDI Pocket Guide. The 2016 version is coming soon!

The 2016 CDI Pocket Guide update is under development, and we’re always looking for customer feedback to make it even better.

Please share your suggestions and any “wish list” items with us at info@hcqconsulting.com.

To learn more about the CDI Pocket Guide, check out the 2015 version on the ACDIS/HCPro Marketplace.

We look forward to hearing from you!

Richard D. Pinson, MD, FACP, CCS

Cynthia Tang RHIA, CCS,

HCQ Consulting