Mastering Clinical Validation Challenges

Clinical validation is an integral part of coding and documentation review, ensuring alignment between diagnoses and the clinical evidence documented in the medical record. While most healthcare professionals are familiar with its importance, the process often comes with recurring challenges. Below, we explore some common hurdles and practical strategies to address them effectively.

Managing Conflicting Clinical Criteria

Even with clear documentation, inconsistencies in the clinical criteria used to support diagnoses like sepsis, acute respiratory failure, or malnutrition can lead to validation issues. Discrepancies often arise when different providers rely on varying standards or interpret criteria differently.

Actionable Strategies:

• Standardize Criteria Across Teams: Establish organizational guidelines aligned with evidence-based protocols, like Sepsis-3 or ASPEN criteria for malnutrition.
• Foster Provider Collaboration: Encourage collaborative discussions between physicians, clinical validation specialists, and coders to reconcile differences.
• Utilize Peer Education: Provide targeted education on how adhering to consistent criteria impacts metrics like case mix index (CMI) and denial rates.

Addressing Documentation Gaps in Clinical Evidence

Incomplete documentation remains a significant barrier to validation, particularly when critical elements like lab results, imaging studies, or detailed progress notes are missing.

Actionable Strategies:

• Promote Concurrent Reviews: Real-time validation during patient care can catch documentation gaps before finalization.
• Optimize Query Processes: Ensure queries are concise and compliant, minimizing provider burden.
• Incorporate Technology: Leverage NLP tools or EHR-integrated prompts to flag missing clinical elements.

Gaining Physician Buy-In

A lack of engagement from providers can slow progress in clinical validation initiatives. Physicians may view validation as unnecessary or overly administrative, particularly when feedback isn’t presented constructively.

Actionable Strategies:

• Share Relevant Data: Use facility-specific data to illustrate how accurate clinical validation influences key metrics such as CC/MCC capture rates, PSI scores, and compliance audits.
• Emphasize Patient Impact: Highlight how validation improves patient safety and care quality, not just reimbursement.
• Streamline Feedback Mechanisms: Ensure feedback is actionable and time-efficient, focusing on high-impact cases or recurring documentation issues.

Resolving Inconsistent Documentation

In complex cases involving multiple providers, differences in documentation styles or terminology can create conflicting narratives, complicating validation efforts.

Actionable Strategies:

• Offer Templates: Offer documentation templates that include all necessary documentation elements, especially for high-risk diagnoses.
• Host Case Reviews: Regular interdisciplinary meetings can align providers on the clinical picture and documentation requirements.
• Provide Feedback Loops: Use real-world examples to highlight how consistent documentation resolves discrepancies and improves outcomes.

Bridging the Coding-Clinical Divide

Differences in interpretation between coders and clinicians often create friction in validation. Coders may feel unsupported in interpreting clinical notes, while clinicians may be unaware of coding nuances.

Actionable Strategies:

• Encourage Dual Training: Offer coders foundational clinical training and help clinicians recognize the documentation criteria required by coding guidelines to foster mutual understanding.
• Deploy Clinical Liaisons: Designate specialists to bridge gaps, offering coders clinical insights during chart reviews.
• Use Data Analytics: Analyze trends in coding errors or validation discrepancies to inform training and process improvements.

Key Takeaways

Clinical validation challenges aren’t insurmountable when tackled strategically. By standardizing criteria, addressing documentation gaps, and fostering collaboration across teams, organizations can streamline the clinical validation process while ensuring compliance and accuracy.

For healthcare organizations looking to refine their clinical validation practices, Health Information Associates provides expert guidance and support. Let us help you optimize your processes for better outcomes and greater peace of mind. 

Since 1992, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.