Podcast: validating clinical claims without medical record review

Automated claim editing systems are a crucial component of accurate and efficient claims payment. But there will always be claims that are too complex to be auto-adjudicated and need a human touch. So, what exactly do you need to clinically validate a claim? In this episode of Cotiviti’s “From the Trenches” podcast, we talk with Kris Jensen, registered nurse and clinical consultant for Cotiviti's Payment Accuracy solutions. 

Listen here as she explains: 

  • How Clinical Validation can be performed without medical record review
  • How hospital claims are used in clinical validation of professional claims
  • What resources are required to perform Clinical Validation
About the podcast:
From the Trenches is a podcast from Cotiviti, a leader in healthcare data analytics, exploring the latest trends in healthcare quality and performance analytics, risk adjustment, payment integrity, and payer-provider collaboration. Check out all our episodes in your browser, or subscribe on your smartphone or tablet with Apple PodcastsTuneInGoogle Play, and Stitcher.

About our guest:

As a clinical consultant, registered nurse, and certified professional coder, Kris Jensen provides subject matter expertise and consultative support for Cotiviti’s Payment Accuracy solutions. With more than 20 years of experience in healthcare, she previously was an RN for St. Mark’s Hospital in Salt Lake City, Utah, before joining Cotiviti in 2006. She also served as vice president of Professional Registry Nurses for eight years.  

Learn more about how Cotiviti's Clinical Validation enables payers to reduce annual claim spend by 1 percent or more from our fact sheet.

Read the fact sheet

Podcast transcript 

We at Cotiviti use the term clinical validation a lot when talking about correct claim payments. What is clinical validation?

Clinical validation is a unique way to review edits with modifiers that would otherwise automatically pay because of the presence of the modifiers; for example, modifiers 25 and 59. We hire registered nurses with experience in the healthcare setting. Once we hire them, we train them to be coders. They become certified professional coders within the first 18 months of hire. Our nurses are able to review claims, gather a clinical picture of the patient, the treatment the provider is performing, along with other providers and treatments to determine if the claim has been coded correctly. 

Why is clinical validation important to health plan claim payment operations?

In 2005, the Office of Inspector General recommended payers implement a pre-payment review of modifier 59. They found that modifier 59 was reported incorrectly 38 percent of the time. CMS agreed with this recommendation. So, clinical validation is a great pre-payment review of these claims and other modifiers. It is an educated review of the claim, the edits, and the modifiers. It is a practical use of cutting waste and abuse for healthcare claims. 

How is it possible to review a claim for clinical accuracy without looking at a patient’s medical record? 

There is a lot of information we can gather by reviewing the claims. We are able to review each claim individually. We review the patient information, the age of the patient, the diagnoses on the claim, along with all of the procedure codes that the provider has reported. We take into consideration the specialty of the provider to get a clinical picture as to why this patient has been seen by this particular provider. When our nurses review the claim, our editor has flagged a line on the claim, indicating there may be a possible over-payment. 

For instance, if we have a provider reporting an Evaluation and Management code with modifier 25, along with a code for a wart removal, our software will flag the office visit with an unbundling edit. When the provider reports the code for the wart removal, the assessment of the wart, the decision to treat the wart, treatment of the wart, and follow-up care instructions is included in the value of the wart removal code. For the office visit to be reimbursed separately from the wart, we review all of the diagnoses on the claim to determine if the provider treated a condition that was separate and significant from the wart. If the only diagnosis on the claim is for the wart, the nurse will apply the edit. However, if the provider is treating another separate condition, such as depression or diabetes, or other lesions that are not warts, our nurses will remove that edit. 

What are the common types of claims on which clinical validation can be performed?

Clinical validation can be performed on claims with a CPT or HCPCS code, so we review all of the provider claims and the outpatient claims. 

How is a hospital claim used in the clinical validation of a professional claim?

Reviewing the hospital claims is beneficial for the clinical validation of the professional claim because it assists the nurses in gathering the full clinical picture for the patient and the patient’s condition. 

For example, let’s suppose the patient is being treated by their orthopedist with injections to their knee for knee pain. The provider may inject the knee with steroids every few months to alleviate the swelling and the pain in the knee to help the person walk better and exercise better. Our editor will flag an office visit with the injection code because remember, the evaluation of the knee, decision to inject the knee, injecting the knee, and follow-up care instructions are included in the value of the injection code. Our nurses will look at recent history to determine if there were any changes for this condition since the provider last injected the knee. 

If we can see a hospital claim with a recent visit to the ER for an additional injury to that knee, or we can see that there was a recent hospital visit with a knee surgery performed by a different provider, we can assume the Evaluation and Management code for this visit will be significant for the change in the patient’s condition. By reviewing the claim from the hospital, it helps us complete the full clinical picture of the patient’s condition and treatments that the patient is receiving.  

How often do you see the need to use hospital claims in this way?

We review the hospital claims for about 85 to 90 percent of the claims that we review. 

Clinical validation definitely sounds like a necessary process, but also very resource-intensive and difficult as well. What does a health plan need to do in order to perform clinical validation efficiently and effectively?

They will need to hire nurses and educate them in coding. We find it takes eight full months to a year to fully train each nurse. They will need to stay abreast on coding rules including NCCI, CMS, CPT, American College of Obstetricians and Gynecologists (ACOG), Coding with Modifiers, and articles published by MLN Matters, and CPT Assistant, just to name a few. 

The health plan will need to hire nurse of different specialties to support the provider reconsiderations. One nurse may be an expert at reading provider documentation for joint surgery, understanding which codes can be paid for when a "compartment" of a joint is treated versus instructions from NCCI for when the joint would need to be “ipsilateral,” or the opposite side of the body, for separate reimbursement. Another nurse with experience in a cath lab would understand how to reimburse a provider reconsideration depending on which vessels were explored and treated.

The coding rules also change frequently. CMS may implement an NCCI edit with code pairs in January but publish a change to the code pairs in May, making it retroactive back to January. Staying on top of the changes in the rules is vital. It takes frequent updates to the rules engine as well as constant, consistent training in the coding changes for the nurses.

Podcast music credit: "Inhaling Freedom" by Nazar Rybak, via HookSounds.


Jeff Robinson
As senior manager of content marketing, Jeff supports Cotiviti's customers by developing a wide range of healthcare communications including blog posts, white papers, case studies, podcasts, and videos. Before joining the organization in 2016, he worked in journalism as the morning host and news director for KCPW, a public radio station in Salt Lake City. Jeff holds a bachelor’s degree in broadcast journalism from the University of Southern California and an MBA from the University of Utah.

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