Can Only a Clinician Perform Clinical Validation?

ICD10monitor April 15, 2024
Erica Remer, MD, FACEP, CCDS, ACPA-C

There has been a kerfuffle on LinkedIn I would like to expound upon today. A colleague of mine, Siraj Khatib, was recently expressing his exasperation at clinical validation audits.

He referred to the Recovery Audit Program Statement of Work (SOW). In 2011, there was a paragraph in the section titled DRG Validation vs. Clinical Validation, which read, “clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician...

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