Clinical validation: A step too far?

March 4, 2020 / By Cheryl Manchenton, RN

Music continues to be a theme in my life. I especially enjoy musical theater and one of my top 20 shows is Aida.  A favorite song is “A Step Too Far” in which the three major characters analyze their choices. They think about their actions and try to understand how they got to this point in their lives. 

So, let’s talk about clinical validation. I wholeheartedly agree that clinical validation is a process that needed to happen and also that it must continue to happen. But how did we get here and have we gone a step too far?

CDI programs have been around for over 25 years. At their inception, they were clinical documentation improvement programs with the main key performance indicator of increased hospital reimbursement. When an individual CDI or department is heavily scrutinized on the financial impact of their work, is it surprising that not everyone operated honestly? I have encountered CDI programs that queried every patient with AMS as having encephalopathy, every patient with malnutrition as severe, and every bump in creatinine as AKI. Those programs (in my opinion) took more than one step too far.

Let’s look at our providers. Many have decided it is easier to just document certain conditions to avoid having to answer queries. In some cases, those conditions may have not actually been present or may not have been clinically significant or relevant to the patient’s hospitalization. I continue to see acute blood loss anemia documented on EVERY orthopedic or cardiac surgical patient at some organizations. These providers have obviously gone a step too far.

It is no surprise that CMS and private payers have chosen to perform clinical validation as healthcare costs and charges have skyrocketed and due to the above-mentioned examples. It also does not surprise (but disappoints) me that hospitals conform to the external validator “definitions” and force providers and patients to fit into those criteria.

But how far should we go?

Here are a few examples of where I think clinical validation has gone too far:

  1. Client A uses an external vendor to do pre bill reviews. Auditor provides clinical criteria and instructs client not to code the condition unless it meets criteria.
  2. Client B leaves it up to individual coders or CDIs on case who don’t code it unless it meets criteria in their institution.
  3. Third party C utilizes criteria for severe malnutrition older than Aspen and denies severe malnutrition in any patient whose BMI is greater than 16.6.

I could go on and on (and on), but what concerns and angers me is that we have taken away medical judgement from the person(s) who should most have it—the bedside provider. Unless the auditor has a medical degree and has actually taken care of real patients, it is inappropriate for them to determine what criteria constitutes a medical condition. And for those providers who remotely review via the validation process without direct visualization of the patient, it is like practicing textbook medicine. Patients do not fit into check boxes of symptoms and criteria. Our hands-on providers are best able to diagnose and treat our patients.

Now, I  am not advocating that providers can document whatever they want and we code it, no questions asked. They do need to explain why the patient’s current picture is different than the vast number of patients with that same condition.

Clinical validation should be a process in which we are asking providers to supplement their documentation to support the patient they are caring for. The process should involve some standard definitions, criteria for validation and escalation processes, but at the end of the day, we need to ensure we have not taken a step (or many steps) too far.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.