Q&A: Clinical validation denials

Q: What is the importance of clinical validation and creating a clinical validation workflow?

Trey La Charité, MD, FACP, SFHM, CCS, CCDS: The problem with clinical validation is that it has become the largest weapon in any payer’s arsenal to deny reimbursement to a facility. It is the vast majority of our MS-DRG validation denials. The actual coding mistakes that auditors catch in my organization are less than 10%. It’s all clinical validation denials insisting that their (the payer’s) physician and clinical criteria are better and more appropriate than ours.

With that in mind, you need a workflow process to defend against these things, and you need a feedback process. I think the feedback process may be even more important than an appeals process, because the payers are just simply taking the position that they’re right, and we’re wrong.

So, you have to make sure the providers are not documenting things that don’t exist.

Okemena Ewoterai, BSN, MA, CCDS, CDIP, CCS: We have been seeing an increasing rate of denials, and we keep talking about how each year it’s increasing. But what are we doing to help offset or prevent that from occurring? Clinical validation helps to provide a framework and guidance on how CDI programs or clinical care centers who have a clinical documentation program should operate.

Even if you have CDI specialists and other processes that are going to help you prevent denials, you need to make sure your physicians are all thinking the same way clinically in terms of criteria and diagnoses. Are you going to attack everything, or are you going to focus on what your payers are trying to deny the most at your institution?

If you have a workflow in place and you start with the diagnoses you want to target and what the organizational needs are, you should be in a better place than trying to target everything, which is going to cause a bit of chaos.

Editor’s note: La Charité is a medical director for CDI and coding at the University of Tennessee Medical Center in Knoxville, Tennessee. Ewoterai is a director of CDI at Montefiore Medical Center in the Bronx, New York. They answered this question on the December 17, 2025 episode of the ACDIS Podcast.