A CDI program plans to develop a policy for addressing diagnoses that require clinical validation.

A compliant clinical-validation process should include a defined escalation process. The AHIMA/ACDIS query guidance specifically recommends organizational query policies that address escalation when a query remains unanswered or when documentation and clinical-validation concerns cannot be resolved through the ordinary workflow. Escalation may involve CDI or coding leadership, a physician advisor, the chief medical officer, or other designated personnel according to organizational policy.

Option A is inappropriate because simply coding every documented diagnosis without addressing significant clinical-support concerns undermines data integrity and increases denial and compliance risk. Option B is also too absolute. Coding professionals cannot independently substitute their clinical judgment for that of the responsible provider; unclear or potentially unsupported diagnoses should be addressed through an established clarification and validation process. Option D is incorrect because queries may appropriately occur concurrently or retrospectively depending on the circumstances and organizational workflow.

The goal of clinical validation is not to force removal or confirmation of a diagnosis. It is to ensure that the provider has an opportunity to clarify whether the diagnosis accurately represents the patient's clinical condition and to document supporting reasoning where appropriate.

CCDS Reference Topics: Professionalism, ethics, and compliance; clinical validation; compliant query policies; escalation procedures.

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