Enhancing Clinical Validation Queries to Address Rising Denials

Clinical validation Queries

The volume of clinical validation denials is increasing, yet clinical validation queries have not kept pace. One key reason for this discrepancy is the complexity involved in constructing clinical validation queries, which require precise and thorough documentation to ensure accurate coding and reimbursement

The Unique Challenges of Clinical Validation Queries

Unlike traditional queries that request providers to add a diagnosis based on clinical evidence, Clinical Validation Queries often ask providers to remove a diagnosis due to insufficient clinical support. This fundamental difference creates several challenges:

  • Provider Expectations: Physicians are accustomed to confirming diagnoses when responding to queries. Since most queries seek clarification or additional documentation, providers may assume the goal is to validate the diagnosis rather than question its validity.
  • CDI Workflow and Technology Limitations: Many query tracking systems were designed to support documentation integrity efforts that add diagnoses, rather than those that seek to remove unsupported ones.
  • Limited Query Templates: Most CDI and coding teams rely on pre-built templates designed to support missing diagnoses. However, they may only have one template for clinical validation, making it difficult to construct effective and compliant queries.

Constructing Effective Clinical Validation Queries

Creating compliant and effective clinical validation queries requires both clinical expertise and strong writing skills. Standard templates often do not suffice, as they can confuse providers who might assume the query is reinforcing a diagnosis rather than questioning it.

Key considerations when drafting clinical validation queries include:

  • Clinical Indicators: What objective criteria should be included to determine if the diagnosis is valid?
  • Question Framing: How should the query be worded to ensure clarity?
  • Response Options: What multiple-choice options should be provided to guide an accurate response?

Additionally, outdated practice briefs previously encouraged providers to add documentation to support a diagnosis even when clinical indicators were incomplete. This guidance likely contributed to the confusion surrounding clinical validation queries, reinforcing the misconception that queries are only used to confirm diagnoses.

The Role of Provider Documentation in Clinical Validation

While additional provider documentation can sometimes help clarify a diagnosis, it cannot make an invalid diagnosis clinically valid if the objective criteria are not met. Certain conditions require specific diagnostic indicators, and without them, the diagnosis remains unsupported.

However, exceptions exist. For example, if a provider deviates from standard treatment due to patient-specific factors—such as avoiding an antibiotic due to an allergy—proper documentation can justify the decision. Nonetheless, in most cases, additional documentation alone will not validate a diagnosis that lacks objective clinical evidence.

Addressing the Reporting and Training Gap

Another challenge is how to report the outcomes of clinical validation queries. Should agreement rates be based on responses that lead to higher reimbursement, or those that ensure a more accurate medical record? These are not always aligned, and the industry must establish clearer guidelines.

To bridge these gaps, CDI and coding professionals need targeted training on clinical validation, focusing on:

  • Identifying when a clinical validation query is necessary
  • Recognizing clinical criteria associated with high-risk diagnoses
  • Crafting compliant clinical validation queries
    • How do clinical indicators differ in validation queries vs. standard queries?
    • How should the question be framed?
    • What response options should be included in a multiple-choice format?

As clinical validation denials continue to rise, CDI professionals must adapt by enhancing their expertise in clinical validation queries. Improving provider education, refining query processes, and leveraging appropriate technology will be crucial in ensuring accurate documentation and compliance.

How to Handle Clinical Validation Denials in Medical Billing

Clinical validation denials occur when insurance companies or payers challenge the clinical necessity of a service provided, leading to a denial of reimbursement. These denials are typically based on the payer’s assessment that the documentation does not support the medical necessity of the treatment, procedure, or diagnostic service billed by the healthcare provider. For medical billing companies like Allzone, clinical validation denials pose a significant challenge, as they can delay reimbursements and impact cash flow.

To address clinical validation denials effectively, medical billing companies must ensure that clinical documentation is complete, accurate, and reflects the medical necessity of the services provided. This includes ensuring that diagnoses, procedures, and treatment plans are appropriately supported by the patient’s medical records. Moreover, it’s crucial for billing professionals to stay updated with payer-specific guidelines, which often change and can vary by insurer.

A robust denial management process, including a thorough review of clinical documentation, appeals when necessary, and timely resubmission of claims, is essential for minimizing clinical validation denials. By addressing these denials proactively, medical billing companies can improve reimbursement rates, reduce claim rejections, and help healthcare providers maintain steady revenue flow while ensuring compliance with insurance requirements.