Clinical validity…It’s not going away anytime soon

September 5th, 2018 / By Cheryl Manchenton, RN

It has been two years since AHIMA updated the Official Guidelines for Coding and Reporting with a statement about clinical validity. You would think with lessons learned plus time and distance we would have seen the focus on clinical validity decline or at least hold steady. Instead, the focus has increased.

Why is this? Let’s break it down into a timeline:

  • August 2016 – Coding Guidelines updated and published.
  • August 2016 – AHIMA published a practice brief further expounding on the need for clinical validity for accurate and compliant coding and reporting.
  • August 2016 – Clinical Validation article authored by AHIMA published in JAHIMA.
  • October 2016 – AHA published a coding clinic including the components of the practice brief.
  • December 2016 – AHIMA published an updated practice brief noting the 2013 RAC scope of work was/is driving who and how clinical validation should be performed.
  • October 2017 – AHA Coding Clinic published noting facilities cannot create policies regarding code omission due to lack of clinical validity.

In a few short months, AHIMA made sure that everyone was fully updated on their official position, guidelines and coding requirements for clinical validation. But still 12 months later, in October 2017, AHA was again asked to validate the how and why of clinical validation. So why can’t we move on? Is it because it is hard to understand? Is it that we are finding it hard to accept, or is it too arbitrary?

I postulate the latter two. The Coding Guidelines and published materials are perfectly clear on when to perform clinical validation and how that affects code assignment. 

So why is it hard to accept? There are several reasons:

  1. Financial losses – Losing that lone MCC on a case (or several cases) can sting financially. Even more so is losing that principal diagnosis (such as sepsis and respiratory failure). If your organization is facing this scenario, my question is a simple one: Did your organization, through resources utilized and length of stay, “earn” that diagnosis?  If so, then go through the appeals process and fight until appeals efforts are exhausted. If not, accept the downgrade and move on.
  2. Level of effort – Performing clinical validity is time consuming, labor intensive and increases DFNB (bill holds). Without an upstream process, the back-end is strongly impacted.
  3. Habit – It goes against the grain of traditional CDI programs to place queries that will negatively impact the CMI. It is also uncomfortable to question the clinical judgement of our providers and can put our hard-earned relationships at risk.

Why is it arbitrary?

This one is easy. Each audit organization can utilize their own set of definitions for diagnoses. For example, one audit organization notes that patients cannot have severe malnutrition unless the BMI is less than 16. Although that is clinically preposterous, without negotiated definitions contractually agreed to, healthcare organizations are at the mercy of the different definitions they utilize and that sometimes differ between the various audit organizations.

Since clinical validation is not going away anytime soon, organizations need to do the following:

  1. Work at the contract level to set definitions for high-risk diagnoses frequently denied for clinical validity.
  2. Set clear organizational standards for performing clinical validity upstream (concurrently) instead of hoping claims are not denied.
  3. Set a culture for complete, accurate and compliant documentation versus a focus on financial goals and gains.

Clinical validity is truly here to stay.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.


Learn more about clinical validity in an upcoming webinar featuring Cheryl Manchenton and Dr. Beth Wolf.