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. On the other hand the Official Guidelines for Coding and Reporting give instructions that the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis. This session will address these conflicting imperatives and propose solutions to this dilemma.
- Define clinical validation
- Explain the distinction between coding regulations and CMS billing regulations and applicable statutes
- Articulate solutions to these conflicting imperatives