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

Progress has been noted on this issue since first reported last July by ICD10monitor.

Since the last Talk Ten Tuesday’s segment in August 2018 about whether HIM Coding Professionals are qualified to query for clinical validity, I am happy to announce that we are seeing some positive changes. Some organizations have started to modify their job descriptions to include additional credentials and backgrounds other than nursing. In addition, both the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS) are also expressing the importance of the clinical validator’s knowledge and not their credentials in journal articles. AHIMA has also published a revised practice brief titled, “Clinical Validation: The Next Level of CDI (January 2019 Update),” to clarify who can write clinical validation queries. Per the practice brief, “the qualifications of a professional who can send clinical validation queries will vary by setting and organization. Many organizations support both CDI and coding professionals as authors of clinical validation queries. Adequately trained query professionals should not be prevented from writing clinical validation clarification queries based on their credentials and/or background (e.g., HIM coding background versus clinical background).”

The topic on whether HIM Coding professionals are qualified to query for clinical validity has evolved over the years due to the evolution of the query process. The query process has become more complicated as healthcare organizations continue to evolve with the ever-changing reimbursement methodologies. Since the quality of patient care and claims data is now impacting reimbursement, the accuracy of provider documentation is now more important than ever. As healthcare organizations are facing more clinical denials, provider documentation is now under more scrutiny and all documented diagnoses must be supported by clinical indicators, treatment, and/or monitoring. As a result, many CDI departments now issue clinical validation queries.

A step in the clinical validation process involves a clinical review of a patient’s health record to identify any potential gaps between the documented diagnoses and the clinical evidence; which is a practice that many HIM Coding professionals have performed when coding a record and issuing a query. But at the end of the day, only a provider can truly validate whether a clinical condition is present or not, therefore many successful clinical validation processes consist of a multi-tier process that is supported by a multi-disciplinary CDI team.

By saying a multi-tier process, a CDI department may have a career ladder that incorporates the clinical validation process. Some organizations are having their senior CDI professionals issuing clinical validation queries, while the rest of the team performs the traditional CDI reviews. These senior CDI professionals, with either a clinical background or a HIM Coding background, will be the first line of defense in the clinical validation process. They will be the ones who will be identifying any potential clinical/documentation gaps and will be the ones issuing the clinical validation queries. The other team members of the clinical validation process will include the providers themselves, who will validate whether a clinical condition exists, and last but not least a physician advisor who may step in when a discrepancy occurs. There should always be an escalation process in place for CDI professionals to follow relative to clinical validation.

As we know the clinical validation process can be a very complicated process, therefore, everyone’s background and experience will add value to the CDI team. A successful CDI professional must possess strong critical thinking skills and have a strong understanding of clinical indicators, in addition to the many documentation requirements associated with specific reimbursement methodologies.

Documentation requirements is typically a learned skillset by professionals with a clinical background whereas it is a skillset that is already possessed by HIM Coding professionals. This understanding of documentation requirements associated with the reimbursement methodologies is critical because it is the foundation of any CDI professional to appropriately identify documentation gaps and to successfully prioritize query and education opportunities. A CDI professional should also be personable and be able to articulate the documentation needs to the provider with confidence, in which, this quality cannot be predicted solely by one’s credential. Therefore, wouldn’t it be fair to say that despite one’s credentials all CDI professionals will require some form of training in either coding and/or clinical process to adapt and/or understand how to look at a health record with a CDI lens.

As a CDI professional it is important to develop and foster any provider relationships no matter what credentials you may have. Mutual respect between providers and the CDI team is gained through one’s ability to share their knowledge in documentation requirements while successfully helping the provider in changing their documentation practices.

In closing, this subject of who can perform clinical validation remains “contentious” across the industry and a lot of changes still need to occur because it is still impacting a group of qualified candidates from being hired. There are still job postings and recruiter postings on social media that specifically highlight a specific type of candidates that can apply. This type of verbiage has caused many qualified candidates with backgrounds like HIM Coding professionals, foreign-trained physicians, respiratory therapists, etc. to be overlooked despite their other qualifications that may make them a stellar CDI professional. As Dr. Erica Remer said during the last Talk Ten Tuesday segment, “it’s not about the credentials but the knowledge of the clinical validator” that matters.

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