Many providers have experienced an increase in clinical validation denials. This is a specific denial category that occurs when clinical evidence in the patient chart is inadequate to support a billed diagnosis. It is not the same as coding, billing or charging errors. It is important to understand the cause of these denials and develop strategies to improve the process. For example, if the provider documents Acute Respiratory Failure, the chart should include ABG values, whether the patient has chronic respiratory compromise and evidence of aggressive measures of oxygen intake. Documentation that is lacking in these areas may lead to denial of the claim. Regardless of your setting, it is important to quickly identify these denials and work with your providers to adequately support conditions documented in the record.
Determining the clinical validity of a reported condition can be subjective, making it difficult to appeal a denial. Payers and healthcare organizations may have their own clinical validation criteria, definitions, and thresholds. What is the required threshold necessary to clinically validate a diagnosis? CMS advises, “As with all codes, clinical evidence should be present in the health record to support code assignment.
Webinar’s Goals:1. Understand clinical validation denials & how to improve2. Review required documentation3. Examples of clinical validation denials & payer disputes4. QIO reviews: What are they looking for?5. Payer & Provider DRG conflicts
Target Audience:CodingBillingRevenue CyclePhysiciansMid-level providersNursesClaims follow-upComplianceAuditorsCDI Staff
