What are Clinical Validation Denials? How to Recognize and Improve

Dorothy Steed

Dorothy Steed

Dorothy Steed (MSLD, CCS, CDIP, COC, CPCO, CPUM, CPUR, CPHM, CPMA, ACSOP, CCS-P, RCC, RMC, CEMC, CPC-I, CFPC, PCS, FCS, CRCR, CICA, CPAR) is an Independent Healthcare Consultant and Educator in Atlanta. She was a Medicare specialist for a large hospital system and a physician audit supervisor for another hospital system, with 44 years of...
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Pre-recorded
60 Mins
Dorothy Steed

Many providers have experienced an increase in clinical validation denials. This is a specific denial category that occurs when clinical evidence in the patient chart is inadequate to support a billed diagnosis. It is not the same as coding, billing or charging errors. It is important to understand the cause of these denials and develop strategies to improve the process. For example, If the provider documents Acute Respiratory Failure, the chart should include ABG values, whether the patient has  chronic respiratory compromise and evidence of aggressive measures of oxygen intake. Documentation that is lacking in these areas may lead to denial of the claim. Regardless of your setting, it is important to quickly identify these denials and work with your providers to adequately support conditions documented in the record.

Webinar Objectives

  • Ability to identify clinical validation denials and why they occur
  • Understand that diagnostic statements by the provider require supporting evidence of the condition.  Can be compounded when the provider is selecting codes.
  • Conflicting provider opinions that are not addressed can contribute to denial activities. 
  • Understand that payers often have specific diagnostic protocols that include expected clinical criteria.
  • Review examples of clinical validation denials and common expectations that should be in the record.

Webinar Agenda

  • Recognizing clinical validation denials
  • Identify causes and trends
  • Financial impact 
  • Developing process improvements

Webinar Highlights

  • Recognize denials associated with clinical validation.
  • Review your top 5-10 denial categories and analyze these claims for patterns with certain diagnoses.  What is missing that would support the billed condition?
  • Query providers when diagnostic statements are not clearly supported with clinical evidence.
  • Develop provider education opportunities for stronger evidence of the billed diagnoses.  Education can include other departments for better outcomes.
  • Education should include the financial impact of documentation deficiencies and inconsistences.

Who Should Attend

  • Revenue Cycle Managers & staff
  • Billers
  • Coders
  • Clinical Documentation staff
  • Finance Managers
  • Denial Management Staff
  • Physicians
  • Midlevel Professionals
  • Claims Follow Up Staff
To access this webinar, kindly reach out to our customer support team at support@complianceducator.com.

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