“Go to those guys and get someone who’s a peer to say ‘Here’s
the diagnostic standard. If your diagnosis doesn’t have these
criteria, the diagnosis is not going to stand up’… A simple example is if there’s a diagnosis of pneumonia but there’s nothing on the X-ray. There are good reasons why it may not be
on an X-ray, so the doctor needs to explain why he put down
pneumonia,” Pinson says.
This is why experts recommend that CDI teams and physicians come together and nail down the clinical criteria they
use to support a diagnosis on commonly disputed conditions.
Haik recommends, for example, that CDI teams work with a
provider’s pulmonologist to develop the provider’s own standard for respiratory failure.
“They should develop criteria that’s evidenced based. So you
can go to the medical journals text and come up with what are
industry standard, evidence-based definitions,” Haik says.
In his consulting practice, Haik educates physicians on the
latest evidence-based clinical definitions for respiratory failure, kidney injury, and all of the most frequently debated definitions. Specialty societies such as the Surviving Sepsis Campaign can be a resource for determining the most authoritative
source for sepsis criteria, for example.
“You need to have specific medical references you can point
to when you’re dealing with a third-party reviewer. That’s the
best way to educate your medical staff, so you can then rebut
any adverse determinations,” he adds.
As CDI specialists know all too well, educating physicians
is challenging in the best of circumstances, so Pinson recommends trying to do educational outreach at times and places
where physicians are generally available, such as medical staff
meetings or section meetings.
“Your most important people are hospitalists because most
hospitals handle the bulk of cases and they consult on surgical cases. They’re a big focus. Even your chief medical officer
ought to do a little leaning on people to get the word out there,”
Pinson advises. ¢
1. Porter, Steven. “Whistleblower Suit Costs Banner $18.3
Million.” HealthLeaders Media. April 12, 2018. www.
Note: The opinions expressed by Suraj Bossoondyal in this article are
his own and not on behalf of Sutter Health. Mary Butler (mary.butler@
ahima.org) is the associate editor of the Journal of AHIMA.
Sample Clinical Validation Query
ACUTE KIDNEY INJURY (AKI), also known as acute renal failure, is among the most commonly disputed diagnoses by clinical
validation auditors, according to CDI experts. Clinical documentation improvement specialists (CDIS) can help providers submit
claims that pass muster by querying physicians for more information before the claim goes out the door. Below is an example of
a query that a CDI specialist might send to a physician, provided by Richard Pinson, MD, FACP, CCS, principal of the consulting
firm Pinson and Tang, LLC.
AKI (acute kidney injury) was documented within the medical record.
Clinical Indicators: Admitted with UTI and dehydration; creatinine 2.0 / BUN 30; mild chronic kidney disease with baseline
creatinine 1. 5; creatinine returned to baseline of 1. 5 with IV fluid
Treatment: IV Fluids
Based on the clinical indicators and your professional judgment, can this diagnosis be further specified? Please complete by
selecting one of the options below:
This diagnosis is not confirmed and/or it has been ruled out.
This diagnosis is confirmed (if confirmed, please add additional supporting information to the medical record).
Other explanation of clinical findings; Click here to enter text.
Unable to determine
Clinical Documentation Specialist
© Pinson and Tang, LLC. Used with permission.