Clinical validation and coding accuracy are two terms often lumped together in discussions about medical billing audits. But they're not the same thing. Understanding the nuances between them can make or break your practice's revenue stream.
What is Clinical Validation?
Clinical validation involves evaluating the clinical criteria to ensure that the diagnoses documented in medical records are not just coded correctly but are also actually supported by clinical evidence. This isn’t about whether the code follows ICD-10 guidelines — it's about whether the diagnosis should have been documented in the first place.
Payers, particularly Medicare Advantage plans, are keen on clinical validation audits. They want to ensure that diagnoses lead to appropriate care and aren't simply listed to increase reimbursement. These audits look for things like medical necessity and whether the diagnosis aligns with the patient's clinical profile. Think of it as a second layer of scrutiny after the code assignment.
Why Payers Are So Focused
Insurance companies are not charities. They scrutinize claims to protect their bottom line — and clinical validation is a tool they wield. For example, if a claim is submitted with a code for congestive heart failure, payers will want to see clear evidence in the medical record: lab results, medications, a cardiologist's notes. Without this, expect a denial.
Consider denial code N570: "Missing/incomplete/invalid principal diagnosis." This isn't just about a missed code. It's about a diagnosis that doesn't stand up to clinical scrutiny. And when 5-10% of claims fall into this trap, it’s a problem worth addressing.
How It Differs from Coding Accuracy
Coding accuracy is about adhering to coding guidelines and conventions. It's the bread and butter of what coders do daily: translate physician documentation into standardized codes. But here's the kicker — a claim can be coded accurately and still fail clinical validation. It happens more often than practices want to admit.
Imagine a scenario: A patient comes in with vague symptoms, and the provider documents "possible pneumonia." The coder assigns an accurate ICD-10 code for pneumonia. This passes a coding accuracy audit with flying colors but might fail a clinical validation audit. Why? Because "possible pneumonia" lacks the necessary clinical evidence.
Who Handles What?
Coders focus on the nuts and bolts of guideline adherence. Clinical validation requires a deeper dive — often involving clinicians who understand medical necessity and clinical indicators. Some practices hire clinical documentation improvement (CDI) specialists specifically for this purpose.
The Payer Perspective and Portal Quirks
Payers like Humana and Aetna have specific portals where clinical validation audits are conducted. Billers know the drill: upload documentation, wait on hold, and cross fingers. It's not uncommon for these portals to be less than user-friendly (a generous way to put it).
Payers aren't just looking for errors; they're also testing your practice's resilience. Can your team quickly gather and submit necessary documentation? How do you handle a denial if it comes? Knowing the peculiarities of each portal can shave days off the process.
Common Denial Codes
Denial codes specific to clinical validation include CO50: "Non-covered services because this is not deemed a medical necessity by the payer." This isn't an issue of incorrect coding. It's about medical necessity — a different beast entirely. Another frequent flyer is CO16: "Claim/service lacks information or has submission/billing error(s) which is needed for adjudication." You might have all the right codes, but if documentation doesn't support clinical necessity, you're out of luck.
Practical Steps to Mitigate Risks
Make clinical validation a regular part of your revenue cycle management strategy. Train staff to recognize common pitfalls. Ensure your documentation isn't just present but robust. Clinicians should be aware that their notes are the foundation upon which coding and billing rest.
Audits Aren't Going Away
Clinical validation audits are not a passing phase. As value-based care models gain traction, expect these audits to increase in scope and frequency. That's why preparing for them isn't optional — it's necessary for survival.
Navigating Clinical Validation Challenges
Handling clinical validation isn't about playing defense. It's about offense, too. Proactively improve documentation, involve clinicians in training, and audit your processes regularly. Implementing these steps reduces denial rates and strengthens your practice's financial health.
The Forward Path
This isn't just about surviving audits; it's about thriving despite them. By understanding and addressing clinical validation, your practice doesn't just defend against revenue loss — it positions itself for better payer relationships and a stronger bottom line. When handled correctly, clinical validation isn't just a challenge — it's an opportunity.
Related Articles
