Challenges of Clinical Validation: Coding Guidelines vs. Billing Regulations

AHIMA December 12, 2022
Richard Pinson, MD, FACP, CCS, CDIP, and Cynthia Tang, RHIA, CCS

What is clinical validation? Why is it important? What’s the big deal? Is it enough to just query the provider?

One of the fundamental challenges for physicians is that they must keep abreast not only of updates to clinical criteria for numerous conditions but also with specific terminology to ensure proper code assignment. Clinical documentation integrity (CDI) programs serve to assist providers with these challenges through education and queries.

Of course, sometimes solutions bring their own problems: Some clinicians have become overzealous in documenting conditions that are commonly queried. This is in part because they’re trying to be good team players but, in some cases, it’s also to avoid queries, which some find annoying and take up precious time. As...

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