Have we been getting it wrong? The anatomy of a misnomer.
By Robin Sewell, CDIP, CCS, CIC, CPC, CCDS
How did the phrase “Clinical Validation” get coined when it comes to queries? As Clinical Documentation Integrity (CDI) professionals, we use that term essentially to “invalidate”, not “validate”, a clinical condition when there are insufficient clinical indicators to support it. …But do providers know CDI speak? Do they understand why they are receiving the query? Have we “mis-named” the query type, creating a misnomer?
How often have you submitted a clinical validation query to rule out a diagnosis only to have the provider “confirm” or “validate” the diagnosis?
To test out my theory, I “crowd-sourced” several Physician Advisors using a query that was the subject of a denial. The denial was for acute postoperative respiratory insufficiency. The payer stated that the patient had normal postoperative weaning status post CABG, and as such, acute postoperative respiratory insufficiency was invalid.
When I read the query, it was obvious to me that the query writer did not think the documented postop respiratory insufficiency was clinically valid, and it appeared their intent was to have it removed, aka “invalidated.”
The Query In Question
Documentation includes the diagnosis of respiratory insufficiency on the pulmonary consult date xx/xx/25.
Clinical Indicators:
xx/10/25 Op note: Operation performed-CABG x2: LIMA to LAD, saphenous vein graft to diagonal, endoscopic harvest of left long saphenous vein…
Post-Op diagnosis: Multi-vessel CAD
XX/10/25 Pulmonary Consult: “… Acute respiratory insufficiency, postoperative-on vent postop, tolerating weaning per protocol…”
XX/11/25 Pulmonary Consult: “… successfully extubated XX/10/25…”
XX/11/25 Hospitalist Consult: “…Acute respiratory insufficiency, postoperative. Symptoms have resolved. Patient is currently on 3 L nasal cannula. He will be weaned off…”
Based on the above, please further specify the patient’s respiratory status:
| X | Acute pulmonary insufficiency following cardiac surgery |
| Acute respiratory insufficiency, postoperative | |
| Hypoxia only | |
| Unable to determine | |
| Other (please specify) |
The intention of the query seemed clear to me: The patient was extubated on the same day as the procedure and was tolerating normal weaning. I agreed with the payer that this was invalid; however, it was not so obvious to the physician.
The Query Hypothesis
To test my hypothesis that physicians often misunderstand “clinical validation” (and to campaign for reforming the query process), I submitted the query to several physicians to get their opinion. It was an informal poll with these options, while encouraging feedback on their thought process:
- The query writer wants me to select respiratory insufficiency (regardless of whether it is postop/pulmonary, etc.).
- Since the diagnosis is already documented, the query writer does not understand/read the clinical indicators very well.
- The query writer suspects the diagnosis of acute pulmonary insufficiency is not clinically valid.
- The query writer wants you to rule out acute or postop pulmonary insufficiency.
- Other
Providers who were not involved in CDI functions and who did not participate in clinical validation denials and appeals confirmed the hypothesis. Here were some of the comments by the physicians involved in the experiment:
- “Why would they think it’s not clinically valid? At the minimum the sedation is not allowing the patient to breath on their own.”
- “I tried to take my knowledge out of the picture, and yes, if you sent this to a physician with minimal insight into coding and CDI, they absolutely would not know what the question is about.”
- “I think I was asked so often in clinical life about these sorts of issues that maybe I never gave it much thought and just answered the best I could, assuming there was a good reason to be asked.”
- “I would pick option 2 since the note on xx/10 states that dx. Also, it states that the patient had adequate oxygenation, with no mention of respiratory distress or hypoxia. Instead, it leans towards a quick wean off oxygen.”
- “…for this case I think it’s straightforward. I don’t think you’d need an MD to validate it.”
These comments were very insightful. They revealed that many physicians do not understand clinical validation, and, as we already know, many do not understand coding guidelines.
Where To Go From Here
So, what can be done to rectify this knowledge/communication gap? As we patiently await more guidance from AHIMA and ACDIS from an updated Query Practice Brief, can we at least call a spade a spade? What is it we really need from the provider? I vote we label these queries very plainly as “Rule Out Diagnosis.” Then, within the query itself, we clearly explain why.
How about this instead? (Bold and italics are for purposes of this article only)
Dear Doctor:
The documentation includes the diagnosis of respiratory insufficiency on the pulmonary consult date xx/xx/25, which has limited clinical evidence supporting it as a valid diagnosis.
Clinical Indicators:
xx/10/25 Op note: Operation performed-CABG x2: LIMA to LAD, saphenous vein graft to diagonal, endoscopic harvest of left long saphenous vein…
Post-Op diagnosis: Multi-vessel CAD
XX/10/25 Pulmonary Consult: “… Acute respiratory insufficiency, postoperative-on vent postop, tolerating weaning per protocol…”
XX/11/25 Pulmonary Consult: “… successfully extubated XX/10/25…”
XX/11/25 Hospitalist Consult: “…Acute respiratory insufficiency, postoperative. Symptoms have resolved. Patient is currently on 3 L nasal cannula. He will be weaned off…”
Based on the above, was the respiratory status normal postoperative weaning from vent, and thus acute respiratory postoperative insufficiency was ruled out:
_ Yes- Normal postoperative weaning from vent (ruled out)
_ No- Abnormal postop weaning from vent: Acute respiratory insufficiency, postoperative is clinically valid.
The Takeaway
This isn’t about changing compliance standards. It’s about improving communication clarity.
Because if the provider doesn’t understand the question, we shouldn’t be surprised when we get the wrong answer.
Maybe it’s time to rethink the term “clinical validation query.”
Because right now?
It might be doing the exact opposite of what we intend.
Query IQ Tip
If your query requires the provider to “read between the lines” … rewrite it.
Clarity isn’t just good practice; it’s denial prevention.
