Strengthening Clinical Validation to Mitigate Payment Denials: Insights from AHIMA’s Practice Brief

In the realm of healthcare reimbursement, understanding and addressing clinical validity is crucial to minimizing payment denials. This blog delves into the significance of clinical validity, with a focus on the top five diagnoses that Enjoin often sees denied by Medicare Advantage programs—Sepsis, Respiratory failure, Severe malnutrition, Encephalopathy, and AKI/ATN. 

 

2024 Coding Guidelines Update

The Practice Brief Clinical Validation (2023 Update) by AHIMA serves as a valuable resource for hospitals and healthcare systems seeking to fortify their clinical documentation against payment denials rooted in clinical validity. While not regulatory, this document is widely recognized as an industry standard, shaping the interpretation of clinical validity by payors. The coding guideline change in Section III states “For reporting purposes, the definition for ‘other diagnoses’ is interpreted as additional clinically significant conditions that affect patient care. These conditions necessitate clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of stay, or increased nursing care and/or monitoring.” The term “clinically significant” is synonymous with “clinically valid,” shedding light on the importance of accurate clinical documentation. 

 

Understanding Clinical Validation

The Centers for Medicare and Medicaid Services (CMS) distinguish clinical validation as a separate process from coding guidelines. This involves a clinical review to confirm the documented conditions align with the patient’s actual health status. This distinction is vital, as many providers may be surprised to learn that coding and clinical validity are not synonymous. To bridge this gap, collaborative efforts are essential, involving Clinical Documentation Specialists, HIM Professionals, and Providers. The Clinical Validation query emerges as a tool to ensure documented diagnoses are clinically valid. Reasons to use a Clinical Validation query are: 

1. The documented diagnosis lacks the usual clinical indicators to support the diagnosis.
2. The diagnosis is no longer valid, but the documentation does not state it is ruled out or resolved.
3. An uncertain diagnosis is carried forward in cut and paste notes from the history and physician to the discharge summary.
4. The diagnosis is valid, but the presentation is atypical and more supporting documentation is needed.

Enhancing the capture of clinically valid diagnoses can significantly elevate the quality of Provider clinical documentation. The Provider learns to generate documentation that supports their clinical impressions and their medical decision making. This proficiency extends to the application of critical terms such as “ruled out” or “resolved” and minimizing cut-and-paste practices. For a comprehensive guide on achieving clinically valid Provider documentation, the section titled “Educational Considerations” in the paper serves as an invaluable summary, offering practical insights to optimize documentation practices.

 

Conclusion

The top five denied diagnoses identified by Enjoin underscore the urgency of fortifying the clinical validation process. Collaboration among HIM Professionals, Providers, and Clinical Documentation Specialists is pivotal in achieving a common goal—creating a more meaningful health record for patients and reducing clinical validity denials from payors. Strengthening this process not only ensures accurate reimbursement but also contributes to a comprehensive and accurate portrayal of patient health.