Clinical validation and denials
from Modern Practice Podcast Hosted by Dr. Tom Villanueva and Vizient Medical Leadership Team
When a clinical diagnosis or procedure is not validated in the medical record, resulting in a claim denial, the health care organization loses reimbursement, the physician or clinician involved may come under scrutiny and the reputations of both clinician and hospital may suffer. Errors in documentation needlessly contribute to this problem. On this episode, we discuss what clinicians and organizations can do to avoid claim denials. Guest speaker: Erica Braun, MS, RN, CCDS Consulting Director Vizient Moderator: Tomas Villanueva, DO, MBA, FACPE, SFHM Principal Clinical Operations and Quality Vizient Show Notes: [01:11] Clinical validation denial [01:31] Implications for denials: downgraded DRGs and lower reimbursement [02:31] Avoiding denials [03:25] When diagnoses are at high risk for denial [03:59] Examples of disputed diagnoses [04:30] Establishing criteria for diagnoses [05:15] What physicians can do to help improve documentation [06:17] What to do when a denial occurs [07:29] Negotiating and coordinating with payers Links | Resources: To contact Modern Practice: [email protected] Erica Braun’s contact email: [email protected] Fact sheet on Vizient’s clinical documentation improvement services: Click here Clinical Validation: The Next Big Challenge in Inpatient Coding (American Academy of Professional Coders, AAPC): Click here Subscribe Today! Apple Podcasts Amazon Podcasts Android Google Podcasts Spotify Stitcher RSS Feed
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