Clinical validation is the process of validating each diagnosis or procedure documented within the health record, ensuring it is supported by clinical evidence in the medical record. Based on the False Claims Act of 1863, CMS does not permit providers to submit claims with codes for conditions that cannot be clinically validated based on authoritative and/or widely accepted diagnostic standards if it results in an “overpayment" and penalties can be severe. Join the HCCS team for this series on hot topics surrounding clinical validation and lessons learned through complex scenarios.

This series includes:

Pneumonia & Sepsis

Upon completion of this session, you should be able to:

• Identify the difference between clinical validation and DRG validation.
• Identify credible sources for clinical advice.
• Describe when a query is needed.
• List clinical indicators for sepsis, and pneumonia.

Encephalopathy & Congestive Heart Failure

Upon completion of this presentation, you should be able to:

• Identify the difference between clinical validation and DRG validation.
• Identify credible sources for clinical advice.
• Describe when a query is needed.
• List clinical indicators for encephalopathy and congestive heart failure.

Acute Kidney Injury & Acute Respiratory Failure

Upon completion of this presentation, you should be able to:

• Identify the difference between clinical validation and DRG validation.
• Identify credible sources for clinical advice.
• Describe when a query is needed.
• List clinical indicators for Acute Kidney Injury and Acute Respiratory Failure.

Find these courses in the School of Coding & Documentation. Subscribers and grant participants, be sure to login prior to enrollment as courses may be available at no cost.