Are HIM Coding Professionals Qualified to Query for Clinical Validity? Part III

Original story posted on: August 20, 2018
It’s not the credentials, but knowledge of the clinical validator that counts.

Clinical documentation integrity (CDI) professionals come from a variety of backgrounds and skill sets. Frequently, we see health information management (HIM) coding professionals and nurses stepping into the role of CDI. Their respective education and experiences help provide a core foundation for these professionals engaging in such an endeavor.
CDI requires training in understanding clinical documentation gaps. It is not often that someone can just step into the role and become a CDI professional overnight. There is a component of analytical skills involved with the job; therefore, if someone asks me whether HIM coding professionals are qualified to query for clinical validity, my response will always be “it is not the credentials (RHIA, RHIT, CCS, RN, etc.) or education background, but the knowledge of the clinical validator that matters.”
Often, many forget or are unaware that many HIM coding professionals were required to pass anatomy, physiology, and pharmacology courses prior to graduating from their accredited HIM programs. Additionally, there are many types of coders (inpatient coder, physician coder, emergency room coder, radiology coder, etc.) with different types of credentials (CCS, CPC, etc.) in the industry, as well as different levels of education. Similarly, there are many different types of clinicians (intensive care unit registered nurse, medical/surgical registered nurse, family medicine physician, surgical physician, etc.) with diverse levels of education and clinical experiences.
Therefore, it is unfair to assume that all HIM coding professionals lack clinical knowledge and are unable to perform clinical validations properly. Besides education and/or experience, what makes a successful CDI professional is analytical skills and ability to understand the role of CDI. Some people may not be successful in CDI despite their education and/or experiences due to their inability to grasp the fundamentals of CDI. The questioning of the qualifications of HIM coding professionals has also unintentionally created challenges for those who are trying to obtain roles in clinical validation and/or CDI.
As mentioned above, the skill set and years of clinical education may differ from person to person, but it is important for one to remember that many of us in the beginning of our careers as CDI professionals were trained by a seasoned HIM professional who possessed a wealth of knowledge about coding and clinical indicators they look for in supporting the coding of a diagnosis.
What stirred up this debate about the qualifications of HIM coding professionals was a statement issued by the Centers for Medicare & Medicaid Services (CMS) referencing clinical validation in 2013. This same statement was also later reiterated in the American Hospital Association’s (AHA’s) Coding Clinic and the American Health Information Management Association (AHIMA) publication Clinical Validation: The Next Level of CDI (December 2016 update). Per the Recovery Audit Contractor (RAC) Scope of Work:

    “Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record. Recovery Auditor clinicians shall review any information necessary to make a prepayment or post-payment claim determination. Clinical validation is performed by a clinician (RN, CMD, or therapist). Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.”

Unfortunately, many in the industry took the assertion that “clinical validation is performed by a clinician (RN, CMD or therapist)” out of context. This was referencing RAC processes and who they have identified to perform clinical validation. It is up to every organization to create their own policy and procedure related to clinical validation. In reality, clinical validation is a multi-tiered process, and a piece of it is already being performed by CDI professionals with all different types of backgrounds.

CDI professionals should be reviewing clinical indicators to identify documentation gaps and/or discrepancies requiring clarification. But in the end, clinical validation should be performed in peer-to-peer fashion. As CDI professionals, we are not part of the clinical team, but are the liaisons between the clinical and coding worlds; as a result, we do not perform as a “peer” when issuing clinical validation queries. CDI professionals are trained on the job, regardless of their background, education, and credentials, to understand evidence-based definitions, rules, and regulations related to coding and industry standards so that these can be incorporated into their review process.

Final clinical validation requires provider-to- provider review. Since many providers do not understand the complexity of coding and documentation, it is very important for CDI professionals to become experts in both coding and clinical reviews. It is your knowledge that qualifies you as a clinical validator, not your credentials as a HIM coding professional or your credentials as a clinician.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Anny Pang Yuen, RHIA, CCS, CCDS, CDIP

Anny Yuen, RHIA, CCS, CCDS, CDIP is an active member of AHIMA and ACDIS. She is the author of First Steps in Outpatient CDI: Tips and Tools for Building a Program & is the co-author of The Complete Guide to CDI Management & many CDI white papers and toolkits.

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