AHIMA Clinical Validation practice brief (2023 update): Should we code diagnoses documented by the provider if they do not meet any established definition or clinical criteria?

I disagree with one portion of the recently released AHIMA practice brief, Clinical Validation (2023 Update). And agree with the rest.


That does not mean it’s wrong. Just that I have a different take on a complex and contentious issue.


My concerns are with this paragraph:


When contracting with payers, organizations should require that Coding Guidelines be followed when reviewing claims to potentially mitigate future denials. According to these Coding Guidelines, if a diagnosis is documented it is considered reportable and the coder must report that diagnosis. The AHA Coding Clinic (Fourth Quarter, 2016, pp. 147-149) Clinical Criteria and Coding Assignment, advises that, if a provider documents a diagnosis, it will be coded. If a clinical validation reviewer later feels that the diagnosis is not supported by the clinical findings and documentation within the health record, it is a clinical validation issue and not a coding error. Additionally, AHA Coding Clinic (Fourth Quarter, 2017, page 110) advises that it is inappropriate for organizations to automatically omit a diagnosis documented by the provider if it does not meet any established definition or clinical criteria. Ideally, only diagnoses that are supported by clinical evidence will be documented within the health record, but that is not always the case.


This is coding guidance and should be followed if you place accurate coding at the pinnacle.


The problem is, if you report a diagnosis documented by a provider that lacks any supportive clinical criteria, your organization will face scrutiny and denials—by payers and possibly the OIG.


This practice can, has, and will lead to heavy fines—and potential false claims action.


That’s the way it is. If you subscribe to the OIG listserve, this government-funded agency is auditing claims and denying codes that lack clinical criteria. They are in effect overriding coding guidance.


If I were a payer I would want to see more than a documented diagnosis—I’d want to see it clinically supported, too.


I agree that reporting a documented diagnosis is not a coding error, and agree that it is a clinical validation issue. But I believe clinical validity of a diagnosis should trump coding guidelines.


Note: This is not what AHA Coding Clinic says. I’m just one voice in the wilderness.


The brief does state that unsupported diagnoses should almost always warrant a clinical validation query. A good clinical validation process will render most unsupported diagnoses a moot point. The brief offers great advice here.


This is a contentious topic, to say the least. But in my opinion, coding rules must come second to protecting an organization from qui tam actions, false claims, and extrapolated penalties.


I’ll admit I could be wrong; possibly I’m ceding too much authority to payers and regulatory bodies over hospitals and physicians.


Coding has gotten much more high-stakes, and clinical validation adds another considerable level of complexity. It would be a miracle if we all had clear, unambiguous policy that both sides, provider and payer, followed.


I commend the group who put this together to address this complexity. I commend every coder working in this environment.


Read the document and let me know you think. Link below.



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