New CMS Guidelines Impact Coder Roles

April 6, 2017 8:57 am

Removal of clinical validation reviews from coding’s purview may increase denials and RAC recoupments.

How is the coder’s role changing in the clinical validation process?

Answer: Clinical validation is the process of reviewing patient information to determine whether patients truly possess conditions documented by physicians in medical records. For decades, these reviews have been conducted by clinical coders as an integral part of coding processes. Coders possess strong clinical knowledge and the ability to formulate appropriate and meaningful physician queries when questions arise or documentation fails to support physicians’ diagnoses.

Because these missing clinical indicators are common reasons for failed medical necessity, payer denials, and Recovery Audit Contractor (RAC) reviews, catching them early in the revenue cycle is imperative. However, new guidelines from the Centers for Medicare & Medicaid Services (CMS) may put a damper on efficient and effective clinical validation reviews.

Clinical Validation Shifts to CDI

CMS suggests that clinical validation is beyond the scope of a coder and should only be performed by a clinician. The American Health Information Management Association (AHIMA) also recommends that clinical validation is the responsibility of clinical documentation improvement (CDI) professionals with clinical background. The result? Coders are rapidly shifting mindsets to capture only what is documented by the physician without reviewing for the supporting clinical indicators in the patient record. Coders are also being deterred from sending physician queries for clinical documentation clarification. We believe these practices will significantly increase medical necessity denials and RAC recoupments later in 2017 and in 2018.

Six Diagnoses to Watch

Given the new CMS guidelines and other recommendations and practices, how can organizations mitigate risk? An important first step is to define common targets for clinical validation risk in ICD-10. Once these are identified and validated, strong communication between health information management (HIM), coding, CDI, revenue cycle, and medical staff helps ensure clinical documentation is complete and accurately reflects the clinical indicators present for each case. Here are six high-risk diagnoses to consider for targeted clinical validation reviews and audits.

Acute kidney injury (AKI). RACs and other auditors often cite AKI criteria in their denial letters. The more prominent criteria sets have typically allowed for either looking at serum creatinine or urine output, but denials auditors are increasingly requiring both metrics to be satisfied.

Encephalopathy. Auditors target encephalopathy because it is a relatively vague diagnosis and often doesn’t have complete documentation support. Furthermore, there are multiple types of encephalopathy. Coding the incorrect type could inaccurately add a complication/comorbidity (CC) or major complication/comorbidity (MCC).

Respiratory failure. There is no uniformly accepted definition of respiratory failure. These patients are often the focus of auditors’ reviews and denials. The clinical validation goal is to determine what is normal for the patient versus what is an acute episode.

Malnutrition. RACs and other third-party auditors cite the lack of clinical assessment that suggests malnutrition, and instead still focus on the body mass index score and lab values. However, hospitals use a more standardized approach such as the American Society for Parenteral and Enteral Nutrition guidelines. Without seeing the patient in person, it is difficult to navigate the complex volumes of malnutrition criteria and clinical indicators.

Congestive heart failure (CHF). Acute CHF is often denied by RACs when the focus of evaluation and management does not differ from a patient in chronic or compensated CHF.

Sepsis. Sepsis case documentation must include expansion of the disease signs and symptoms beyond the original infection and have a new focus on organ dysfunction or failure and altered mental status.

A Path Forward

Given the disparity between new Medicare guidelines and traditional coding practice, a new clinical validation workflow is required. The path forward includes clinical validation audits performed by CDI specialists with coding credentials, or teams of CDI and coding professionals, working collaboratively toward the same goal—high-quality clinical coding and DRG assignment.


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