Book excerpt: Clinical validation basics

By Cheryl Ericson, RN, MS, CCDS, CDIP and Cathy Farraher, RN, MBA, CCM, CCDS for ACDIS CDI Blog

Clinical validation is a process in which diagnoses already written in the chart are reviewed by a clinical documentation specialist to ensure the corresponding clinical indicators and treatment exist alongside them, thereby “validating” the diagnoses. It is the most challenging and difficult type of review, and therefore should be performed by the CDI specialist with a strong clinical and coding background and with a seasoned history in CDI.

With the rapid expansion of CDI programs into almost every inpatient hospital setting has come the unfortunate practice of some clinicians documenting “key” diagnoses without the clinical findings and supporting evidence to justify and support them. This can happen for several reasons—they may be trying to eliminate further queries, trying to help the hospital’s bottom line and quality metrics, trying to ensure their length of stay remains in line, or they may simply not fully understand the scope CDI efforts. This puts a lot of CDI professionals in a difficult position, one that makes many very uncomfortable.

Although the term CDI is relatively new, “HIM professionals have been retrospectively querying physicians for more complete patient information for years, and professionals working in utilization review, case management, coding, and quality assurance performed documentation improvement activities before CDI specialist positions became mainstream,” writes Mary Butler in a July 2014 Journal of AHIMA article titled “Reinventing CDI: Organizations Relaunching And Reworking Data Integrity Efforts, And Coding Roles, With Clinical Documentation Improvement Programs.” However, Butler writes, the “difference is that in the last several years, dedicated CDI specialists have focused on documenting care delivery while the patient is still in the hospital.”

With this nuanced difference in the timing of medical record reviews comes a greater opportunity to ensure the most accurate information gets captured— in real time, not in 10 days, or 20 days, or months after the patient has left the hospital. It also provides patients, physicians, and facilities with real-time opportunities for effective communication, data analysis, and overall process improvement.

Clinical validation takes concurrent CDI efforts a step further, requiring a deeper dive into the complexities and hidden compartments of the medical record for clues of care that perhaps weren’t brought forward by the attending physician. It requires CDI professionals to continue with their reviews despite having obtained necessary documentation for CC/MCC capture, beyond even expanded reviews for quality-related payment issues, such as present-on-admission and patient safety indicators.

These reviews can be daunting, but remember how daunting it was to be new to CDI in the beginning, remember how intimidating that felt. Remember, too, that everyone in CDI has opportunities to learn and grow. It’s part of what makes this profession special, challenging, and exciting.