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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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