Clincal Documentation

The topic of clinical validation has been the source of recent confusion among CDI professionals as they attempt to sort out the facts surrounding their role. In an attempt to clear some of the confusion, it may be valuable to first examine the role of the CDI professional and how that crucial role fits into the process of clinical validation.

One can look at 10 CDI programs and likely see 10 different viewpoints and definitions on the role of the CDI professional. There are several credible organizations providing insight into the definition of the role of the CDI professional. One of these is Association of Clinical Documentation Improvement Specialists, the national organization for CDI professionals, where a generic fundamental role definition can be found in the ACDIS position paper, Defining the CDI specialists Roles and Responsibilities, outlined by the following:

“The CDIS facilitates modifications to clinical documentation through concurrent (pre-bill) interaction with providers and other members of the healthcare team. He or she promotes capture of clinical severity (later translated into coded data) to support the level of service rendered to relevant patient populations.”

Ensuring supporting documentation for the services provided is the foundational role of the CDI professional. Without supporting documentation, all that remains is a list of diagnoses. To strengthen the importance of supporting documentation, the UHDDS definitions for diagnosis reporting as stated in the official guidelines also require evidence for code assignment.

As an advocate for the patient and to ensure the medical record precisely outlines the encounter, it is the ethical duty of the CDI professional to assist the provider in his/her documentation of diagnoses and clinical indicators to support the level of services rendered. During a concurrent record review, the CDI professional accomplishes this by noting three broadly defined documentation scenarios:

  1. Documentation of a precise diagnosis with evidence in the record that the condition exists
  2. Documentation of a condition without evidence in the record that the condition exists
  3. Evidence in the record without the documentation of a precise diagnosis or condition

The first scenario, “Documentation of a precise diagnosis with evidence in the record that the condition exists”, is understood to be the ultimate goal of CDI. This is the aspect of the documentation that reflects the success of CDI professional/provider engagement – relevant evidence of a precise diagnosis.

The next scenario, “Documentation of a condition without evidence in the record that the condition exists” signifies clinically ‘invalidated’ scenarios, containing either weak evidence or no evidence of a condition’s existence. Recently, the verbiage surrounding this topic is being called ‘clinical validation’, with the understanding that this denotes the type of query that is to be performed in an attempt to clinically validate a documented diagnosis. The confusion may lie in the fact that the verbiage ‘clinical validation’ is also the process that every CDI professional moves through during a record review, and therefore, we have the term clinical validation being used to denote both a query and a process. The clinical validation query can be a difficult situation and the intricacies approaching the topic of clinically invalidated documentation and subsequent querying is beyond the scope of this blog.

The third and final broadly defined scenario noted during a record review is “Evidence in the record without the documentation of a precise diagnosis or condition.” This is the scenario that generates the majority of queries, the ‘gap’ in documentation, so to speak; though, in order to identify any gaps in documentation, there first must be identification of the clinical indicators, or supporting documentation for a diagnosis; essentially, the diagnosis must either be clinically validated or clinically invalidated. If the documentation of a diagnosis is clinically invalidated, the CDI professional proceeds with a query.

Did you notice the verbiage ‘evidence’, which is contained in each documentation scenario? That evidence (or lack thereof) is indicative of the clinical validation process which is the key to the CDI professional’s role. Regardless of the broadly outlined documentation scenario discussed, evidence is the key factor.

In the record review and clinical validation process, the CDI professional has a responsibility to ensure, to the best of his/her ability and the responsiveness of the provider, that the documentation of each diagnosis is clinically validated and that the clinical indicators signify the documentation of the most specific diagnosis, to the best judgment and extent of information apparent to the provider.

Respectfully submitted,
Karen Newhouser, RN, BSN, CCM, CCDS, CCS, CDIP
Director of Education, MedPartners

Reference

ACDIS. April 1, 2014. Defining the roles and responsibilities of the clinical documentation improvement specialist. Position paper. HCPro, a division of BLR. Retrieved from https://acdis.org/resources/defining-cdi-specialist%E2%80%99s-roles-and-responsibilities

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