Clinical Validation

CMS has redefined the rules in the Recovery Audit Statement of Work (SOW), released September 2011, which officially introduced the term “clinical validation” and directs reviewers to question unsupported diagnoses and procedures.

Clinical validation was a hot topic of discussion in many of the physician-lead presentations at AHIMA’s Clinical Coding Community meeting in October. Physicians are very aware of the game changing decision that opens the gate for reviewers to question them on clinically unsupported diagnoses and procedures. In the SOW, CMS defines DRG validation as the process of reviewing physician documentation and determining whether the correct codes and sequencing were applied to the billing of the claim. A certified coder performs the DRG validation review and focuses on what is documented by the physician and determines if code assignments are consistent with official coding guidance.

Clinical validation is defined as the process of clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. A clinician performs the clinical validation review.

RAC auditors have been performing clinical validation reviews and denying claims when the clinical indicators in the record do not support the reported diagnoses and procedures. Even before the RAC program, physicians were challenged on the validity of diagnoses, such as, respiratory failure, sepsis, and acute blood loss anemia and recently, acute kidney failure has become a big focus of clinical validation.

The process of clinical validation is not the coder’s responsibility, but the coder does play a key role in ensuring existing documentation supports listed diagnoses and procedures. Inaccurate or insufficient documentation is responsible for two common challenges in the code selection


1. Clinical indicators in a chart without physician documentation of the associated diagnosis, this includes pictures of decubitus ulcers, malnutrition documented by nutritional services, acute blood loss anemia identified in labs with, prescribed medications or therapies.

2. Documented diagnoses without clinical evidence to support or “validate” the diagnosis. A physician query can resolve challenge number one, but our hands have been tied when addressing challenge number two. It has been taboo to query a physician on a diagnosis determined to be clinically unsupported as this is viewed as questioning the physician’s clinical judgement. However, CMSs latest SOW for the RAC encouraged to coders to work with clinicians to address inadequate documentation to support diagnoses, procedures, and therapies.

Both DRG validation and clinical validation are retrospective reviews, conducted after the codes have been assigned. The goal of the coder and CDIS is to identify documentation issues prior to final code assignment. Here are some examples I have seen recently where the clinical picture does not “appear” to support the physician’s diagnoses and procedures.
• A review of the lab results finds low potassium levels present on admission, the diagnosis listed in the History and Physical is hyperkalemia. This may be a transcription error, but the physician is responsible for the diagnoses in the H&P and will need to “validate” the diagnosis of hyperkalemia or correct it.

• A urinary tract infection is listed on the Discharge Summary because the patient exhibited some mild lower abdominal pain and dysuria the night before discharge so the physician ordered a urine culture and sensitivity, and a course of oral antibiotics to treat the suspected UTI as an outpatient after discharge. However, the urine culture was negative. A negative urine culture does not eliminate the possibility of a UTI and this finding may prompt a need for the physician to “validate” the presence of a UTI. Discussion with the physician may lead to a more definitive diagnosis of acute cystitis.

• GI hemorrhage as the principal diagnosis, a colonoscopy performed during the admission finds multiple conditions in the intestinal tract but the physician notes no specific site of the bleed. Query the physician to identify the site, (or suspected site in the inpatient setting), of the bleed. The physician may state the site of the bleed site cannot be determined. This needs to be documented to justify assignment of a 578 Gastrointestinal hemorrhage category code along with the conditions identified during the exam.

• Intestinal obstruction due to incisional hernia listed as the principal diagnosis. Review of the operative report finds the incisional hernia is isolated to the abdominal wall and the bowel obstruction caused by a dense pocket of adhesions deep within the peritoneal cavity. Query the physician for clarification on this diagnostic discrepancy. This change in the game plan does not mean a coder or CDIS is to challenge the physician’s clinical judgement, but opens the gate for us to ask for clarification to support the diagnosis when the current clinical evidence in the medical record is unclear or inadequate to the support the diagnosis documented by the physician. As we all know, there are times when the clinical picture described in the record does not truly represent the patient severity of illness. A physician directly responsible for the care of the patient has the final word on diagnoses and may be asked to explain his/her diagnosis when the clinical evidence does not meet established clinical criteria. It is best to involve a physician advisor or other clinician working with the physicians on documentation issues to review these types of discrepancies with the physician.

To summarize, the rules of the game for diagnosis and procedure code reporting:

1. Physician documentation drives code selection.

2. A coder is responsible to review the entire medical record; this includes lab results,
radiology reports, anesthesia record, ancillary care notes etc.

3. Diagnostic statements must be justified by clinical evidence, tests results and treatment
rendered during the encounter for care.

4. Query the physician when discrepancies or contradictory information are identified in the record, this includes ancillary tests and other provider’s notes that conflict with the attending physician’s diagnoses.

5. Partner with clinical professionals or a physician advisor to address documentation issues. Do not forget the rules for principal and secondary code selection.

6. The principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission to the hospital.

7. Code only additional diagnoses the affect patient care in terms of requiring: Clinical evaluation; or

Therapeutic treatment; or

Diagnostic procedures; or

Extended length of hospital stay; or

Increased nursing care and/or monitoring

Let’s take a look at a couple examples and review how best to address these types of issues.

Postoperative ileus

A 57-year-old male presented for Nissen fundoplication repair of a large hiatal hernia. The surgery was uncomplicated. Postsurgically he had a NG tube in place and PCA for pain management accompanied by Toradol. On post op day one, he complained of nausea without vomiting, which gradually decreased over the next couple of days. His pain was managed well on PCA, and he was ambulating frequently without difficulty. His PCA use decreased after postop days one and two. He remained n.p.o. until he began to pass gas on post op day four, at which time his NG tube was discontinued and he was started on a liquid diet. He tolerated the liquid diet without complication and on day five, he was transitioned to a soft diet and switched to p.o. pain meds. On post op day six he was ambulating well, had good pain control and tolerating soft foods with increasing flatus. He was discharge home in stable condition.

Discharge diagnoses: 1. Large hiatal hernia 2. GERD 3. Postoperative ileus

Procedure: Nissen fundoplication repair of hiatal hernia

Clinical indicators to support post op ileus include the NG tube placement, nausea and four- days before bowel sounds return. An index search on postoperative ileus (ileus > postoperative) finds code 997.49 Other digestive system complications. But, before this code is assigned, the physician should be queried to “validate” whether the post op ileus is truly a postoperative complication, related to narcotics for pain management, electrolyte imbalances, other cause, or is this ileus an expected outcome of
the procedure.

If the physician indicates the ileus is due to medication, code the ileus as an adverse effect. Assign code 560.1 Intestinal obstruction without mention of hernia; paralytic ileus, and the E code to identify the medication contributing to the condition.

Postoperative atelectasis
A 62-year-old obese female undergoes an uncomplicated coronary artery bypass x3. A routine postop chest x-ray performed on postop day one finds a small pulmonary atelectasis confined to a segment of the left upper lobe. Postop orders include incentive spirometry, encourage coughing and deep breathing, and early ambulation. The patient did have a mild fever of 99.4F on postop day one, which resolved late that evening. No additional chest x-ray was done. On postoperative day three, the patient was discharge to home in good condition.

Discharge diagnoses: 1. CAD with unstable angina 2. Postop atelectasis 3. Obesity 4. Smoker

Coding clinic, fourth quarter 1990, page 25, tells us “a postoperative atelectasis is often an incidental radiographic or physical finding that is frequently a self-limiting condition, in which case it would not be reported. If, however, it is associated with significant findings, such as fever, or requires further diagnostic or therapeutic work up, such as chest x-ray or respiratory therapy, or is linked to an extended hospital stay, then it would be reported as 997.3 Postoperative respiratory failure. See the Alphabetic Index under Complications, respiratory, postoperative, NEC. Code 518.0 may be added to identify the specific complication as atelectasis”
I know many coders struggle with this type of case, they feel the clinical picture is vague as to whether the atelectasis should be reported as a postop complication. The chest x-ray is routine with no subsequent chest x-ray, the fever may or may not be related to the atelectasis and they wonder if the incentive spirometry and early ambulation is because of the presence of the atelectasis found on x-ray or because of the patient is a smoker and overweight. This is an example of where the coder should call upon their clinical colleagues who can review the case from a clinical perspective, and discuss with the physician to determine if this is a true complication of the surgery.

Danita Arrowood, RHIT, CCS is an educator/developer for Precyse University ( and an AHIMA Approved ICD 10 CM/PCS Trainer. Danita has
over 25 years of coding and auditing experience in both inpatient and outpatient settings. She is currently a reviewer for AHIMA’s Professional Certification Approval Programs and has taught as an adjunct instructor at an AHIMA-approved college in the health information technology associate programs.

Centers for Medicare and Medicaid Services. “RAC Statement of Work.” September 1, 2011

Quiz Questions:

1. Clinical validation is the process of proving the diagnostic statements in the record

support the code assignment.

Answer: False. Clinical validation is defined as the process of clinical review of the case to see whether or not the patient truly possesses the conditions that were documented.

2. Physician orders are acceptable documents to use in determining code selections.

Answer: True.

3. A condition described as “postoperative” describes a postoperative complications.
Answer: False. The term postoperative describes a period of time, not a surgical complication.

4. Which of the following would NOT support secondary code assignment.
a. Malnutrition noted in nutritional notes

b. Physician documented postoperative pain requiring additional medication

c. Physician ordered follow up chest x-rays to evaluate postop atelectasis documented

d. Emphysema listed on the anesthesia H&P

Answer: A . Nutritional notes are not acceptable documentation to refer to for selection of diagnoses, but can be referenced in a physician query asking for this documentation
in physician notes. in the progress notes

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