Healthcare leaders have found many benefits in moving CDI professionals away from the traditional MS-DRG review model. Expansion into areas such as APR-DRG review, office based practices and quality incentives have been successful. However, only slightly more than 50% of CDI programs have access to, or utilize, payer denial data (ACDIS Conference 2017).  Therefore there can be inaccurate gaps in actual CDI performance metrics. While a CDI program’s success is measured at the time of final billing, few programs measure the negative impact of the down the road recovery auditing of those claims. There are numerous reasons for this lack of data sharing. Often the denial management team and CDI program are under separate health system departments. Also, the software tracking of these separate functions is not integrated. Furthermore, the time lag on recovery auditing can be years after discharge.

Recovery auditors review inpatient claims for correct coding, such as sequencing, POA, procedures and discharge disposition assignment. However, recovery auditors also go beyond a general coding review and perform clinical validation of significant diagnoses impacting the inpatient stay. Clinical validation takes auditing a step further to determine if, in fact, the diagnoses coded meet general consensus definitions of that condition. The CMS Recovery Audit Contractor Scope of Work 2013 includes the following statement, “Clinical validation is an additional process that may be performed along with DRG validation. Clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record…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 with approved credentials”. Generally, clinical validation is performed by registered nurses with a coding credential and physician guidance and/or review.

Without knowledge of their facility’s denial data, especially clinical validation denials, a clinical documentation professional is unable to take concurrent corrective action nor provide physician education for problematic documentation. Knowledge of baseline performance is a key element CDI programs must obtain to have an impact on preventing unnecessary denials. It would be important to know your denial risk areas including: diagnoses, integral conditions, combination codes, incorrect POA assignment, conflicting diagnoses and any queries which were deemed leading.

Part 2 will discuss clinical validation of these high risk diagnoses.  


25 year old man presented s/p new onset of witnessed seizures.  In the ER, patient was agitated, confused to place and time and required IV Ativan. Neurology consult was done and an EEG was performed confirming seizure activity and suggestive of “encephalopathy”. Patient remained confused for several hours and documentation noted patient remained “drowsy” into the next day. He was discharged on day 2 after being started on Keppra and no further seizure activity was noted throughout the stay. The physician documented on the discharge summary: AMS, post-ictal due to new onset seizures.

Question: A CDI professional should:

  1. Ensure the AMS is coded as principal diagnosis
  2. Ensure the seizure is coded as principal diagnosis
  3. Do nothing, either can be coded as principal diagnosis
  4. Ensure the seizure is coded as principal diagnosis and query for encephalopathy


Answer: b

Coding Clinic Fourth Quarter 2013, pg 89-90 states encephalopathy due to the post-ictal state is not coded separately since it is integral to the condition.