The Qualification Question

By Selena Chavis for For the Record

On what side of the clinical validation argument do HIM professionals fall?

Are seasoned coding professionals competent or trained well enough to interpret clinical terms and concepts from the medical record? This question was posed on a Talk Ten Tuesdays podcast last year, and the robust response received from listeners reflects how provocative this subject has become across the health care industry.

Chuck Buck, publisher of ICD10monitor and executive producer of Talk Ten Tuesdays, recalls publishing a story on the topic after asking the aforementioned question. “The topic solicited many comments, creating a contentious debate, since Part I was published in the ICD-10monitor e-News on July 17 and discussed the same day on Talk Ten Tuesdays,” he says.

As a follow-up to the original article and in response to feedback, author Debra Beisel Denton, RHIA, CCS, CCDS, CDIP, CRCR, CICA, wrote: “An individual professional working as a clinical documentation improvement specialist, whether a nurse, coding professional, or member of some other discipline, should have a high capability for cognitive analysis and the ability to use and integrate significant clinical information. It is relevant to acknowledge that educational differences between those holding the CCS, RHIA, and RHIT certifications may be significant, and may or may not include formal college credits in anatomy and physiology, clinical pharmacology, and pathophysiology, among other areas.”

Anny Pang Yuen, RHIA, CCS, CCDS, CDIP, a consultant with AP Consulting Associates and a special guest on the podcast segment, says the debate over whether coding professionals are qualified to query for clinical validity has surfaced with greater force in recent years due to the evolution of the query process.

“The query process has become more complicated as health care continues to evolve and quality of care is tied to payment methodologies and claims data,” she explains. “As health systems are facing more clinical denials, clinical documentation is now under more scrutiny, and all documented diagnoses must be supported by clinical indicators, treatment, or monitoring. As a result, many clinical documentation improvement (CDI) departments now issue clinical validation queries.”

Erica Remer, MD, FACEP, CCDS, a clinical documentation and ICD-10 consultant, believes many in the industry misinterpreted verbiage from the 2013 recovery audit contractor (RAC) statement of work that defines who can perform clinical validation as criteria that apply to all organizations. The definition notes that clinical validation “is beyond the skills of a certified coder and can only be performed by a clinician or a clinician with approved coding credentials.”

“This has been misinterpreted as applying to the personnel at institutions, but it is a rule for the RAC, not us,” Remer says. “CDI teams have used this statement of work as support for being the only ones qualified to do clinical validation as opposed to coders, but this is not accurate.”

In addition, Yuen points out that both the American Hospital Association’s Coding Clinic and the December 2016 update of the AHIMA publication “Clinical Validation: The Next Level of CDI” reiterated this statement, leading to more confusion regarding who is qualified to perform clinical validations.

To clarify the matter, AHIMA published a revised practice brief of “Clinical Validation: The Next Level of CDI” in January 2019, which states that “the qualifications of a professional who can send clinical validation queries will vary by setting and organization. Many organizations support both CDI and coding professionals as authors of clinical validation queries. Adequately trained query professionals should not be prevented from writing clinical validation clarification queries based on their credentials and/or background (eg, HIM coding background vs clinical background).”

Yet, the debate continues. Buck points to the following statement from reader A. Czahor as a typical response from readers of the ICD-10monitor article. “I remember a time when it was encouraged to have nurses and physicians on your team because they could speak to the patient care team in a way that coders couldn’t,” Czahor wrote. “AHIMA and ACDIS [Association of Clinical Documentation Improvement Specialists] and others on this thread did a tremendous job of ensuring that everyone had to play by the same rules, regardless of credentials, and [that] all queries, whether verbal or written, should be delivered in a compliant and nonleading manner. This clinical validation interpretation seems to have caused regression, and we’re once again carving out tasks that a nurse or physician can perform differently because of their credentials. I believe we must tackle this issue with the same ferocity that compliant queries were addressed. For example, does this open the door to my clinical validation queries being overturned because they were generated by a coder and not a clinician?”

An Increasingly Contentious Subject

Jon Elion, MD, FACC, founder and chief innovation officer with ChartWise Medical Systems, says an increase of payer denials related to clinical validation is a primary contributor to the debate over qualifications. Putting the risk in perspective, he explains that if a hospital’s denial rate goes up from just 3.5% to 5%, this modest-appearing increase can result in multimillion-dollar losses.

“In the course of my work, I have the opportunity to talk with hospital CFOs across the country, and they are all telling the same story: The percentage of claims that are being denied is on the increase,” Elion says. “I recently reviewed the chart of a patient for whom a claim was denied, with the statement, ‘These are noncovered services because this is not deemed a “medical necessity” by the payer.’ The chart showed that the patient had sepsis with all of the possible clinical indicators and documented. The denial was overturned after appeal, but this still cost the hospital money to have the staff create the paperwork to challenge the denial.”

On some occasions, Elion says the basis for a denial is clear cut—for example, billing for ICD-10 code N17.0 (Acute kidney failure with tubular necrosis) when there is no evidence on the chart to support the tubular necrosis (such as casts in the urinalysis or an elevated fractional excretion of sodium). In this case, it is easy to identify that the hospital should have billed N17.9 (Acute kidney failure, unspecified).

“Querying for clarification on this is well within the talents, training, and purview of HIM coding professionals and clinical documentation specialists,” Elion says.

Remer explains that coders and CDI professionals may find conditions listed in the medical record that do not seem to be supported by the clinical indicators or documentation. Ultimately, though, only a clinician can validate that a clinical condition is or isn’t present. Remer believes coders may be capable of recognizing diagnoses that do not seem to be supported by the clinical indicators according to common diagnostic criteria.

“If the coder feels comfortable and competent to query the provider compliantly, I do not object. Organizations that do not have clinical documentation improvement specialists (CDISs) may have no alternative,” she emphasizes. “However, in facilities that have CDISs who are ready, willing, and able to do clinical validation, they are the logical choice.”

Yuen believes that career opportunity also plays into the evolving industry contention related to coder qualifications for clinical validation, pointing out that job postings on social media often use specific verbiage such as: “To be considered, you need to be an RN.”

“This type of verbiage causes many qualified candidates with backgrounds like HIM coding professionals, foreign-trained physicians, respiratory therapists, etc, to lose an opportunity to even submit their résumé or be presented to the hiring manager for consideration despite their other qualifications that may make them a stellar CDI professional,” Yuen says.

Buck believes that coders, by and large, may feel undervalued within the framework of this discussion. “They work under pressure nearly all the time and, no doubt, many probably feel a lack of self-esteem. So, when a topic such as the one we are discussing surfaces, I think it triggers a defense mechanism, along with the assertion that ‘Yes, we are well trained and have sufficient skills and education level, so back off,’” he says. “On the other end of the spectrum, I have heard clinical documentation integrity specialists actually demean coders and seem to put them on a lower level in the food chain of medical documentation and coding.”

Knowledge vs Credentials

Yuen is on board with a statement made by Remer during the Talk Ten Tuesdays segment: “It’s not about the credentials but the knowledge of the clinical validator.”

“Some CDI professionals and some consulting firms in the industry seem to strongly believe that someone’s background or credentials in a clinical setting should be a requirement to being hired to perform clinical validations because of their clinical backgrounds,” Yuen says. “Many forget that there are many different types of clinicians and that not all clinicians have the foundation of understanding all disease processes and the many documentation requirements associated with specific reimbursement methodologies—for example, MS-DRG [Medicare severity diagnosis-related group] and risk adjustment—which they will need to be taught when they transition their career into CDI.”

She says many coding professionals have completed coursework that includes anatomy and physiology and pharmacology. In addition, some have deep experience issuing queries with clinical indicators, a qualification that CDI professionals may not have. “Therefore, wouldn’t it be fair to say that despite one’s credential, the CDI professional will require some form of training in either coding or clinical process to adapt and understand how to look at a health record through the lens of CDI?” Yuen asks.

Buck believes comments made by reader/listener P. Evans in response to the article and podcast accurately reflect what he has heard and read recently. Evans wrote: “I am certain many other HIM professionals have issued ‘clinical validation’ queries effectively and compliantly for years. At the site (encounter) level, I believe that the background of the clinical documentation specialist is not material. What is relevant is that the query be written in a skillful manner and issued with proper context, clinical support, and citations, and that compliant choices be offered.

“HIM professionals have been involved in the process of clarifying physician documentation far longer than the CDI industry has been around, and HIM professionals bring strong subject matter expertise to the table that is necessary for success,” Evans continued. “As an HIM professional in a CDI role, I have at times felt abandoned by my professional organization, AHIMA. When I first wanted to obtain a CDI credential because I was building a program from the ground up at my local facility and wanted to demonstrate my expertise, ACDIS was my only option. AHIMA was late to the party, in my opinion, and I don’t think they’ve really ever demonstrably caught up. Was there some internal decision not to try to compete with ACDIS?”

Elion believes the debate over HIM qualifications would become much less contentious if payers would provide clearer documentation guidelines. “If it has been written, the coder can code it, but the payer may still deny payment, basically saying ‘prove it,’” he points out. “I don’t wish to imply that physicians and hospitals are guiltless in this conundrum, as busy physicians may not always take the time to carefully document the evidence or the ‘linkages’ between the evidence and the diagnoses. And some CDI programs have gotten a bit creative in their queries, documentation requests, and coding.”

Going a step further, Elion suggests that payers begin publishing their criteria for diagnoses and stating what criteria they are using to determine medical necessity and triage into the appropriate level of care. “Everyone would benefit from transparency of criteria being applied, together with well-documented charts that are correctly and appropriately coded and billed,” he says.

At the same time, physicians, CDSs, case managers, and HIM must become more rigorous and complete in their documentation. Offering an example, Elion notes that it is no longer sufficient to document, “The patient has decompensated congestive heart failure, will admit for diuresis.” Instead, a note should offer a much more detailed synopsis such as “The patient has a history of chronic systolic congestive heart failure (CHF) due to ischemic cardiomyopathy and now presents with decompensation (acute-on-chronic CHF) manifested by marked lower extremity edema (new), rales halfway up both the lung fields (new), and marked jugular venous distension. He is markedly hypoxic on room air with an O2 saturation of 85% and unable to walk even short distances without further desaturation.”

Looking ahead, Yuen emphasizes the value of a multidisciplinary, multitier process, pointing out that not all professionals with backgrounds in nursing, medicine, and coding automatically make successful CDI professionals.

“Everyone’s background will add value to the multidisciplinary team, but one must possess strong critical thinking skills, an understanding of clinical indicators, and a strong understanding of the many documentation requirements in many reimbursement methodologies,” she says, describing this as a learned skillset coders already possess. “This understanding will be the foundation for the CDI professional to identify documentation gaps and to successfully prioritize query and education opportunities.”