dred percent of the cases we took all the way to the ALJ level
were always found in favor of the hospital.”
Ultimately, an auditor didn’t treat a patient—a physician
did—so the burden of proof is on the auditor, Czahor says, and
it is more difficult for RACs to make their case at the ALJ level.
Preventing and Responding to Clinical Review Audits
Without a doubt, CDI professionals are best positioned to
help stave off clinical validation denials by reacting to these
audits. This requires CDI specialists to have a higher level
of clinical knowledge so that they can tell if the documentation specificity is enough to justify a diagnosis—upon which
a code is based. They also will need to be able to teach doctors to document in a way that they are using evidence to
support their diagnosis without actually leading doctors to
a diagnosis with their queries—a tricky balancing act. In
anticipating reviews CDI specialists need to forge stronger
connections with physicians, empower coding professionals to query more thoughtfully, and iron out their own criteria for problem diagnoses.
“It’s not just about getting illness that’s not documented,
documented, it’s also about validating diagnoses that are documented but not clinically supported. Queries will definitely
go up,” in anticipating audits, says Suraj Bossoondyal, MBChB, CDIP, CCDS, CCS, CPC, director of the CDI program at
Sutter Health Valley Area.
Bossoondyal leads a CDI team comprised of foreign-trained
physicians as well as registered nurses. “It’s kind of like peer to
peer. Even though you’re not side by side with the physician,
it’s kind of like shadowing, an observer, so you know how the
physician is approaching a case. You can follow providers and
understand how to approach him based on the specific point
you’re trying to raise,” Bossoondyal says.
To prevent audits, Bossoondyal says it’s important to have
regular education sessions with physicians and suggests
getting a physician champion involved. For clinical validation reviews, practicing evidence-based medicine is important—having providers and CDI teams updated on the
most current clinical criteria. Bossoondyal favors a strategy
that lets the CDI specialists take responsibility for identifying the documentation gap, while letting coding professionals fully focus on final coding. There should be a strong
partnership between the two teams, CDI and coding, to ensure a smooth process with the common goal of accurate,
compliant documentation and accurate, compliant coding,
Richard Pinson, MD, FACP, CCS, principal of the consulting
firm Pinson and Tang, LLC favors a similar strategy with CDI
specialists since they are usually the ones querying physicians
and pressing them to follow established clinical guidelines.
And CDI specialists, for example, are the ones noticing if physicians are frequently over-diagnosing certain conditions like
acute kidney injury (AKI) without providing the documentation that meets the clinical criteria for the diagnosis.
Overly Aggressive CDI Comes with Great Risk
IN THIS REGULATORY environment CDI specialists and coding professionals might feel pressured to query physicians more
frequently, but they do so at their own risk. Physicians can grow weary and complacent if they receive more queries than
they feel are clinically relevant. Worse than that are cases where providers violate the False Claims Act by repeatedly coding
and documenting conditions that don’t actually exist. In one whistleblower case that reached a settlement recently, Banner
Health hired a clinical documentation consultant who said she witnessed repeated instances of inflated numbers and falsified
documentation all in an effort to net higher reimbursement, according to an article by HealthLeaders Media. Banner agreed to
an $18 million settlement with the Department of Justice. 1
Amy Czahor, RHIT, CDIP, CCS, vice president of optimization and analytics services at RecordsOne, says these types of
cases are industry outliers. But that doesn’t mean providers shouldn’t make every effort to ensure false claims don’t happen.
She says it’s ingrained in the ethos of coding professionals and CDI specialists to ask themselves whether every condition
listed on a chart is monitored, evaluated, and treated. CDI specialists themselves also need to make sure they don’t pressure
physicians to over-document or inflate the documentation through their queries.
“We need to make sure these conditions are reportable and a physician wasn’t just in a hurry to get someone off their back,”
Czahor says. “It’s just like when we started being paid by MS-DRGs, they started auditing the DRGs. Now that we’re being
incentivized on CC and MCC capture, you’re seeing increased scrutiny on that.”
To counter this mindset and incentive structure, it’s important for coding professionals and CDI specialists to perform their
own clinical validation reviews to prepare for third-party audits. In this case, the best defense is a good offense. Czahor says
providers are starting to think more critically when they query on a diagnosis such as respiratory failure. For example, if a pa-
tient is diagnosed with respiratory failure and the patient has normal arterial blood gas levels, a clinical validation query may
be needed to confirm the diagnosis.
“We’re seeing a lot of programs and departments expand into that [clinical validation] because program leaders have said,
‘We want you to look at these cases and maximize reimbursement, but we also want you to mitigate risk if a physician is saying something that does not to appear to be clinically supported and would be seen in an audit,’” Czahor says.