ACDIS day1-21 track4-4 pres 0517-Combs Endicott-f · MelanieEndicott, MBA/HCM, RHIA, CHDA, ......

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Melanie Endicott, MBA/HCM, RHIA, CHDA, CDIP, CCS, CCS‐P, FAHIMA, AHIMA‐Approved ICD‐10‐CM/PCS Trainer

Senior Director HIM Practice ExcellenceTammy Combs, RN, MSN, CDIP, CCS, CCDS, AHIMA‐Approved ICD‐10‐CM/PCS Trainer

Director of HIM PE/CDI Nurse PlannerAHIMA, Chicago, IL

A Breakdown of the AHIMA Clinical Validation Practice Brief

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Identify when clinical validation of a diagnosis is needed after reviewing a health record

– Discuss ways compliance within an organization can help support the clinical validation process

– Assess ways to recognize clinical indicators and recognize vulnerable diagnoses for clinical validation

– Discover ways to gain consensus on the clinical validation process

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2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Polling Question #1

• Have you read the “Clinical Validation: The Next Level of CDI” practice brief?

– Yes

– No

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The Need for Clinical Validation

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Clinical Validation vs. Clinical Validation Queries• Performing final clinical validation

– Making the final validation of a diagnosis based on the supporting clinical evidence

• Identifying a clinical validation query opportunity

– Clarification of a possible gap in the clinical evidence


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“Managing an Effective Query Process,” 2008• “Providers often make clinical diagnoses that may not appear to be consistent with test results”

• “For example, the provider may make a clinical determination that the patient has pneumonia when the results of the chest x‐ray may be negative”

• “Queries should not be used to question a provider’s clinical judgment, but rather to clarify documentation when it fails to meet any of the five criteria listed: Legibility, completeness, clarity, consistency, or precision”

• Reliable, timely

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“Guidelines for Achieving a Compliant Query Practice,” 2013 • Query is appropriate when the health record documentation “provides a diagnosis without underlying clinical validation”

• “When a practitioner documents a diagnosis that does not appear to be supported by the clinical indicators in the health record, it is currently advised that a query be generated to address the conflict or that the conflict be addressed through the facility’s escalation process”

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Clinical Validation: The Next Level of CDI

Recovery Audit Contractor (RAC) Scope of Work (SOW) document: “Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or post‐payment claim determination. Clinical validation is performed by a clinician (RN, CMD or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.”


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Clinical Validation: The Next Level of CDI • “Based on CMS’s guidance, it appears clinical validation may be most appropriate under the purview of the CDI professional with advanced clinical education and a background in conducting clinical reviews”

• “Individual facilities need to establish their own criteria for the credentials, education, and experience required of their CDI professionals and develop processes to ensure collaboration between CDI and coding professionals”

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FY 2017 ICD‐10‐CM Official Coding Guideline A.19.• Clinical validation is a separate function from the coding process

• Codes are based on physician documentation, not a particular clinical definition or criterion

• Facilities should have a process in place to validate clinical conditions prior to completing the coding process

• Clinical validation is to ensure not only accurate coding but to also reflect the accurate clinical scenario

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Examples

• Pneumonia with a negative chest x‐ray

• Acute respiratory failure with normal ABGs

• Severe malnutrition with a normal BMI


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Examples

“78‐year‐old female presents with a change in mental status, fever/chills, painful urination, and feeling weak all over. Physician exam reveals tachycardia with a temperature of 102 degrees, with all other systems within normal limits. Admit diagnosis: Sepsis due to UTI. Day 1 progress note: Patient less confused; frequent & painful urination; started on oral antibiotics. Day 2 progress note: WBC within normal limits; temperature 99 degrees, continue with course of antibiotics and discharge. Discharge diagnosis: Sepsis.”

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Sample Query

Sepsis was documented as a discharge diagnosis in this patient with the following clinical scenario (see above). Based on standard recognized clinical criteria for sepsis [Note: Include documentation here of facility criteria or other standard criteria for sepsis], can you please clarify the status of sepsis, as follows:

�Sepsis was confirmed�Sepsis was ruled out�Sepsis was without clinical significance�Unable to determine�Other ______________

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Guidelines for Building Consensus on Challenging Clinical Cases

• Collaborative CDI/coding meetings

– Occur on a regular basis

– Address current and ongoing documentation issues

• Second‐level reviews

– Assist in ensuring accuracy in challenging cases

– Review the record to validate an accurate and complete clinical picture

– Note where opportunities for additional documentation or clarification exist

– Provide feedback to the CDI and/or coding professional

http://bok.ahima.org/PB/ClinicalValidation#.WNFwJoffOpo


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Polling Question #2

• Who sends clinical validation queries at your facility?

– Coding professionals

– CDI professionals

– Both coding and CDI professionals

– Other

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Compliance Supports Clinical Validation

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Ethical Standards for CDI and Coding

“Ethical Standards for Clinical Documentation Improvement Professionals” and “Standards of Ethical Coding”

• Professional guidance for addressing issues such as:

– Compliance

– Decision‐making processes and actions

– Expectations for making ethical decisions in the workplace

– Demonstrating commitment to integrity

http://bok.ahima.org/doc?oid=101609#.WNFwcIffOpo


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Ethical Standards for CDI and Coding

• AHIMA guidance is relevant to all CDI professionals

• CDI professionals have an obligation to demonstrate actions that reflect ethical principles and guidelines

http://bok.ahima.org/doc?oid=101609#.WNFwcIffOpo

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High‐Quality Clinical Documentation

Legible

Reliable

Precise

Complete

Consistent

Clear

Timely

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Achieving Compliance

• Develop a standardized query policy

• Audit record reviews

• Monitor and audit queries

– Small sample of coded records

– Provide one‐on‐one education

• Share RAC audit findings

• Determine a threshold of clinical evidence


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Ways to Recognize Clinical Indicators and Vulnerable Diagnoses for Clinical Validation

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Determining Clinical Validity

• Clinical validation is a subjective process

• It is important to remain within your professional scope

• Final determination is made by a provider of the treating medical team who is qualified to establish a diagnosis

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CMS Requirements

• Complete medical record entries

– Provide sufficient information to identify the patient

– Support the diagnosis/condition

– Justify the care, treatment, and services

– Document the course and results of care, treatment, and services; and promote continuity of care among providers


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Questions to Ask When Reviewing Clinical Indicators

• Would the provider come to the same conclusion based on the same information?

• Is the diagnosis a reasonable conclusion based on the totality of the health record?

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Internal Guidelines

• Defining vulnerable diagnoses

• Created in collaboration with medical staff

• Goal to promote consistency

• Impact of computer‐assisted coding (CAC)

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Caught in the Middle

• Uniform Hospital Discharge Data Set (UHDDS)

• Many diagnoses lack a standardized definition

• Internal policies can provide guidance

– Outline a process


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Address Retrospective Denials

• Education

• Front‐end process changes

• Encourage an emphasis on the clinical evidence in documentation

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Ways to Gain Consensus on the Clinical Validation Process

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Gaining Consensus

• Clearly define expectations

• Streamline communication

• Identify discrepancies prior to billing

• Create a resolution process


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Questions to Consider

• Is the CDI professional required to query the provider for clarification at the coding professional’s request?

• Does the coding professional query the provider?

• Is a query necessary if the CDI professional is qualified to complete a clinical validation review?

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Facilitate Collaboration Between CDI and Coding Staff

• Increase education for staff

• Develop an effective query process

• Conduct regular meetings to discuss issues

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References

• AHIMA BoK (2016). Clinical Validation: The Next Level of CDI.Retrieved from: http://bok.ahima.org/PB/ClinicalValidation#.WIJQCk3fOpo

• AHIMA BoK (2016). Ethical Standards for Clinical Documentation Improvement Professionals. Retrieved from: http://bok.ahima.org/doc?oid=301868#.WIJRPU3fOpo

• AHIMA BoK (2016). Guidelines for Achieving a Compliant Query Practice. Retrieved from: http://bok.ahima.org/doc?oid=301357#.WIJQXk3fOpo

• AHIMA BoK (2008). Managing an Effective Query Process. Retrieved from: http://bok.ahima.org/doc?oid=84610#.WIJQ503fOpo

• AHIMA BoK (2016). Standards of Ethical Coding. Retrieved from: http://bok.ahima.org/doc?oid=106344#.WIJRi03fOpo

• CDC (2016). ICD‐10‐CM Official Guidelines for Coding and Reporting. Retrieved from: https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf


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Thank you. Questions?

[email protected]@ahima.org

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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ACDIS day1-21 track4-4 pres 0517-Combs Endicott-f · MelanieEndicott, MBA/HCM, RHIA, CHDA, ......

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