Clinical Validation Queries: A Missed Opportunity?

Cheryl EricsonBy Cheryl Ericson RN, MS, CCDS, CDIP

Cheryl is a renowned Clinical Revenue Cycle expert with extensive experience in Clinical Documentation Integrity (CDI), query development, quality improvement, and denial management.

For nearly a decade, CDI and coding professionals have worked to refine clinical validation queries, yet many organizations still struggle with their implementation. In her recent article, Cheryl explores the complexities of clinical validation queries shedding light on the challenges CDI teams face when aligning provider documentation with payer expectations. Expanding on that discussion, let’s examine why clinical validation queries remain underutilized and how hospitals can strengthen their CDI workflows to reduce denials. 

Why Clinical Validation Queries Matter 

Clinical validation queries are critical in preventing denials by ensuring that documented diagnoses are backed by sufficient clinical evidence before they appear in claims data. However, many organizations continue to see a gap between the number of CDI queries issued and the number of clinical validation denials, specifically. Given the rise in payer scrutiny, hospitals should proactively validate diagnoses before claims submission—rather than reacting to costly denials after the fact. 

A proactive approach can help: 

  • Minimize revenue leakage by preventing clinical validation denials. 
  • Reduce administrative burden associated with costly appeals. 
  • Ensure consistency in documentation to withstand payer audits. 

The Hidden Cost of Post-Discharge Denials 

One of Cheryl’s key takeaways is that payer clinical validation criteria are often more stringent and less transparent than bedside providers’ criteria, which leads to an increasing number of denials that hospitals must later dispute. The American Hospital Association (AHA) estimates that providers’ costs tied to denials account for over 40% of hospital expenses. 

Instead of relying on back-end appeals, hospitals should track clinical validation denials and assess whether CDI teams could have intervened earlier with a validation query. A few critical questions to consider: 

  • Did CDI review these cases before claims submission? 
  • Was there an opportunity to issue a validation query that was missed? 
  • Do existing CDI workflows promote proactive validation before a weakly supported diagnosis is reported? 

Strengthening CDI Efforts Through Clinical Validation 

Organizations should integrate clinical validation as a standard part of the CDI process to improve documentation integrity and mitigate risk. This means: 

  • Educating CDI teams on payer expectations and common clinical validation pitfalls. 
  •  Developing clear internal definitions for commonly queried and denied conditions to ensure consistency. 
  • Tracking clinical validation denials and linking them to CDI interventions to refine best practices. 

A well-structured clinical validation process ultimately helps hospitals protect revenue, reduce denials, and enhance documentation accuracy. 

Ready to Improve Your Clinical Validation Process?

Clinical validation queries are essential to avoiding denials and improving revenue cycle efficiency. Learn how refining your approach can reduce administrative costs and prevent revenue leakage.

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