The Clinical Documentation Specialist’s Guide to Validation Queries
Clinical Validation and the Clinical Documentation Specialist’s Role
As healthcare documentation evolves, we’re moving far beyond simply recording diagnoses in a patient’s chart. Today’s healthcare environment demands a deeper level of validation—one that ensures every documented diagnosis is supported by solid clinical evidence. At the heart of this process stands the Clinical Documentation Specialist (CDS), whose role has become increasingly crucial in maintaining documentation integrity.
The Essence of Clinical Validation
Clinical validation stands as the cornerstone of accurate healthcare documentation. It demands more than merely accepting a documented diagnosis—it requires a thorough evaluation of supporting clinical evidence. This systematic validation process ensures both documentation integrity and appropriate reimbursement.
When we talk about the purpose of clinical validation, we’re really discussing three interconnected goals. First, it ensures that our DRGs (Diagnostic Related Groups) accurately reflect both the patient’s condition and the resources needed for their care. Second, it confirms that our documented diagnoses align with accepted medical standards. Finally, it verifies that we have enough clinical evidence in the record to support each condition documented and ultimately coded.
To Query or Not to Query: That Is the Question
The decision to initiate a clinical validation query often sparks debate among healthcare professionals. However, CMS has made their stance clear: clinical evidence must support code assignment. While they don’t define specific diagnoses (except in certain coverage determinations), they expect the documentation to tell a coherent clinical story.
This requirement isn’t just bureaucratic paperwork—it serves as a vital shield against denials and supports the medical necessity of our care decisions. When we query appropriately, we’re not just checking boxes; we’re ensuring that our documentation accurately reflects the patient’s clinical situation.
The Right Person for the Right Task
Clinical validation requires a unique blend of clinical knowledge and documentation expertise. That’s why it typically falls to clinicians, particularly Clinical Documentation Specialists, to perform this vital function. Unlike coding professionals, who focus on assigning codes based on documented conditions, CDSs must evaluate the clinical evidence itself.
Think of it this way: while a coder can identify that pneumonia is documented in the chart, a CDS can evaluate whether the clinical indicators—fever, cough, chest X-ray findings, and lab results—support that diagnosis. This distinction is crucial for maintaining documentation integrity.
Building on Evidence-Based Foundations
When we validate clinical documentation, we’re not working in a vacuum. Instead, we rely on a robust framework of evidence-based resources. UpToDate serves as a frequent go-to source, but we also turn to authoritative guidelines from organizations such as ASPEN for nutrition-related diagnoses or KDIGO for kidney disease. The Sepsis-3 criteria has revolutionized how we document and validate sepsis cases.
Many facilities also develop their own physician-approved clinical criteria, creating a standardized approach that reflects their specific patient population and practice patterns. This combination of national guidelines and local standards provides a solid foundation for validation decisions.
The Art of Query Creation
Writing an effective clinical validation query is more art than science. The key lies in presenting objective data from the record while giving providers the opportunity to add their clinical insight. For instance, rather than simply questioning a sepsis diagnosis, we might present the vital signs, lab values, and clinical findings, then ask the provider to clarify their clinical judgment.
Every query should include options for the provider to rule out the condition or select “other” and provide additional explanation. This approach respects the provider’s clinical judgment while ensuring thorough documentation.
Moving Forward with Confidence
The importance of clinical validation in today’s healthcare environment cannot be overstated. It’s not just about compliance or avoiding denials—though these are certainly important considerations. At its core, clinical validation is about ensuring that our documentation tells an accurate, complete, and supported story of patient care.
For Clinical Documentation Specialists, understanding when and how to query for clinical validation represents a critical skill. By approaching each case with careful consideration of the clinical evidence, regulatory requirements, and documentation standards, we can help ensure both quality patient care and organizational compliance.
As healthcare continues to evolve, the role of clinical validation will only grow in importance. By maintaining our focus on evidence-based practice and clear communication with providers, we can meet these challenges head-on, supporting both optimal patient care and accurate documentation.
Remember, effective clinical validation isn’t about finding fault or creating extra work—it’s about ensuring that our documentation truly reflects the outstanding care we provide to our patients every day.
