Developing: Clinical Validation versus DRG Validation

By Allen Frady, RN, BSN, CCS, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
Original story posted on: August 24, 2016

Going back to the late 2000s, when I worked as a contract coder full-time, we were constantly being told both to code and not to code the same diagnoses under the same circumstances and by the same physicians. 

Depending on what day it was, and who was the last person to talk to our in-house auditor, we might be told we should have reported a diagnosis because it was present. Then the very next day, after speaking with quality or clinical documentation improvement (CDI) professionals, or getting the latest audit results, we were then told not to code the diagnosis. To make matters worse, we were never really given any rationale behind the inconsistent guidance. “Just do as we say” seemed to be the order of the day. Logic was not a part of the discussion. If we called out leadership over the contradictory guidance, our concerns were basically ignored. 

Jump forward nearly half a decade, and it seems that not much has changed.   

Consider clinical validation versus DRG validation. How far can or should a coder go with regard to the task of clarifying a physician diagnosis? Coders have certainly been facing a lot of contradictory instruction between the official guidelines and the auditors who are reviewing their work. On the one hand, coding guidelines have always instructed coders to report the diagnoses of the physicians who care for the patients directly.

On the other hand, auditors have become increasingly critical of coders who report diagnoses given by even attending physicians if the diagnoses appear unsupported by the clinical indicators in the medical record.

The response of the coding leadership runs the gamut. I have seen facilities that have opted to ignore and not report any problematic diagnosis. I have seen facilities take the “we code what the physician says” approach. I have seen facilities opt to instruct their coders to hold such records and query. I have also seen facilities opt to instruct their coders to return the records to their CDI team for a determination and to initiate a query if they feel it is merited.

As you may know, the American Health Information Management Association (AHIMA) has been publicly pushing the trend to clinical validation as advanced coder practice, integrating the role of both CDI specialist and coder into a single job. As of Oct. 1, if you have a discharge with a problematic diagnosis given by a physician and the query process fails to yield a different diagnosis, the facility is required to report the diagnosis they had initially. As I have mentioned previously, in many cases physicians still ignore or change their diagnosis after receiving a query. It seems that now would be a great time to be running one of the Recovery Auditors (RAs)!

So, what do we do? In some cases, I believe we will have to change the discussion. It is perfectly fine for any physician to stick with their diagnosis, obviously, so rather than attempting to get a diagnosis change in the form of a clarification as a result of a query, perhaps we need to work with the physicians to help develop good habits and connect the dots for the auditors by plainly documenting the justification.

Suggestions for how to improve: clearly link the diagnostic findings, signs and symptoms, response to treatments, and medical rationale for why the physician believes a diagnosis is clinically validated – in spite of the fact that it may have first appeared not to meet the typical indicators one might routinely expect.    

Medical necessity is not going to go away just because the 2017 coding guidelines have new language putting a stop to diagnosis censorship. While it may be harder on the auditors to argue that there is a coding error, they will still have no problem denying claims based on their policy (or whatever criteria their medical director has elected to use as grounds for a denial).

Two things may change in the next cycle. Denials will quite possibly increase in frequency, and the importance of a good CDI program will have never been greater. This underscores the pressing need to eliminate internal and external audit-induced mixed signals and confusion that have plagued the coding profession for three decades.

About the Author

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation, and compliance.  His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

Contact the Author

AFrady@hcpro.com

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