CDI Clinical Validation and Coding Audits

Jocelyn E. Murray
RN, CCDS

What are the similarities and differences between a CDI audit and a coding compliance audit? Why are both even necessary? It is our collective responsibility to provide the insight that defines the two specialties and the critical efforts both bring to the table.

A CDI audit may incorporate clinical validation within its scope of review practice. Clinical validation audits are typically completed by a clinical practitioner, nurse, physician, or other medical provider. The Journal of AHIMA, June 2017, noted the following in a featured article referencing coding audit trends:

“It is not the coder’s responsibility to decide whether to assign a code based on their interpretation of clinical criteria… ensuring required documentation and code assignment requires strong collaboration with HIM, CDI team, and physician liaisons.”

A CDI audit identifies when possible diagnoses are not specified in the record but are clinically evident within the clinical data, (lab reports, etc.), and in the medical record documentation. On the other hand, coding audits identify the accuracy and compliance of coded data, acuity level, linking conditions as established by CMS and the ICD-10-CM/PCS Official Guidelines for Coding and Reporting.

While those auditing for CDI practices need to abide by the same rules governing code assignment as outlined within the coding conventions, Official Guidelines for Coding and Reporting and Coding Clinic for ICD-10-CM/PCS, they are not required to be coders, (although many hold coding credentials), or code the record.

Additionally, CDI audits often have a focus on patient quality, safety, and risk measures documentation capture. The October 2017 Official Guidelines for Coding and Reporting included the following comment:

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

Further, CMS officially distinguished between the coding audit and CDI/clinical validation audit performed by clinicians, (internal or external auditors), in the following summary:

“Coders must assign what is documented in the record by the provider. Clinical auditors identify what is clinically indicated and not captured in the documentation or if the diagnosis is noted, it is without identified clinical support to validate coding on the claim encounter.”

CMS provides MedLearn Matters fact sheets as references that point to areas of insufficient documentation discovered and typically triggered for a Recovery Auditor (RAC) denial and downgrade, calling on CDI and coding professionals to query providers and rectify documentation deficiencies. Auditing and monitoring internal CDI and coding efforts will provide insight to potential RAC targets and offer the additional insight in documentation integrity and educational needs of Practitioners, CDI specialists, and coding staff.

There are no distinctions made between clinicians who practice as CDI auditors for a facility, practice, or providers, and those who perform the role for CMS as Recovery Auditors or other third-party payer systems. We are clinical practitioners who clarify unspecified diagnostic terms when clinical signs, symptoms, and ancillary test results reveal additional severity, acuity type, or a link to another diagnostic condition. Clinical practitioners that meet the criteria set forth by CMS may query the provider and provide education related to documented diagnoses lacking integrity, clinical validation, and/or enough detail to enable accurate code assignment.

Coding audits enable facilities to identify opportunities for improvement in code assignment and compliance in CMS coding guidelines established. CDI audits identify opportunities for enhanced queries and missed opportunities for proposed capture. Both are needed to ensure our medical records are as complete and accurate as possible.

The blended model of CDI and coding audits promotes the highest level of both documentation integrity and coded data accuracy for inpatient and outpatient practices today. Access to both resources and a defined blended process will provide a return on investment in both patient safety and resources used for care.

Editor’s note: Murray is a senior CDI consultant for HIM services at ComforceHealth. Her subject matter expertise includes: consultative CDI services, training and education, and implementation of new programs. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board. Advice provided is general. Contact Murray at: jocelyn.murray@comforcehealth.com.