22.2 Selecting Cases for Second-Level Review

AHIMA Certified Documentation Integrity Practitioner CDIP

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1 Chapter 1: Authoritative Coding Resources & Conventions

1.1 Official Coding Resources: Scope, Authority & Research 1.2 General Coding Conventions, Punctuation & Instructional Notes 1.3 Chapter-Specific and Setting-Specific Coding Guidelines

2 Chapter 2: Principal & Secondary Diagnosis Determination

2.1 UHDDS Definitions & Principal Diagnosis Selection 2.2 Two or More Diagnoses Equally Meeting Criteria 2.3 Secondary Diagnosis Reporting Standards & POA Status

3 Chapter 3: Procedure Coding & Sequencing Standards

3.1 ICD-10-PCS Root Operations & Inpatient Procedure Coding 3.2 Principal Procedure Selection & Surgical Sequencing 3.3 Applying Official References to Ambiguous Records

4 Chapter 4: Inpatient Prospective Payment & DRG Grouping

4.1 MS-DRG Logic, CC/MCC Exclusions & Severity Levels 4.2 Working vs. Final DRG Assignment & Optimization vs. Maximization 4.3 CDI-Coding Reconciliation & Annual Regulatory Updates

5 Chapter 5: Enterprise CDI Promotion & Program Value

5.1 Articulating CDI Value to C-Suite & Hospital Leadership 5.2 Organizational Models, Inpatient/Outpatient Scope & Staffing 5.3 Cross-Functional Collaboration: HIM, Quality & Case Management

6 Chapter 6: Cross-Functional Alignment & Improvement Projects

6.1 Partnering with Nursing, Pharmacy & Allied Health Professionals 6.2 Documentation Improvement Project Identification & Scoping 6.3 Executing, Piloting & Measuring CDI Project Outcomes

7 Chapter 7: Physician Champion Engagement & Clinical Advocacy

7.1 Selection, Role & Credibility of the CDI Physician Champion 7.2 Peer-to-Peer Engagement, Coaching & Overcoming Resistance 7.3 Developing Standard CDI Operational Policies & Procedures

8 Chapter 8: Compliant Policy Architecture & Query Governance

8.1 AHIMA/ACDIS Practice Brief Standards in Policy Construction 8.2 Medical Record Integration of Provider Query Responses 8.3 Policies for Electronic, Paper, and Verbal Query Communications

9 Chapter 9: Query Escalation & Professional Communication

9.1 Chain of Command & Protocols for Unanswered Queries 9.2 Conflict Resolution & Professional Feedback Mechanisms 9.3 Assessing Stakeholder Learning Needs & Specialty Curricula

10 Chapter 10: Educational Delivery & Broader Healthcare Impacts

10.1 Delivery Methods: Microlearning, Case Studies & Grand Rounds 10.2 Documentation Impacts on Clinical Research & Epidemiology 10.3 Documentation Impacts on Case Management, LOS & Reimbursement

11 Chapter 11: Clinical Record Synthesis & Encounter Trajectory

11.1 Synthesizing Provider Notes, Consults & Progress Trajectory 11.2 Interpreting Diagnostic Imaging, Pathology & Labs 11.3 Resolving Conflicting, Ambiguous & Copy-Forward Entries

12 Chapter 12: Advanced Clinical Concepts & Review Prioritization

12.1 Pharmacotherapy, Clinical Trajectories & Disease Correlations 12.2 Inpatient Review Prioritization: High-Risk & High-Volume 12.3 Payer Prioritization, Length of Stay & Re-Review Cadence

13 Chapter 13: Clinical Indicator Mapping & Gap Recognition

13.1 Systematic Identification of Documentation Gaps 13.2 Sepsis Definitions, SEP-1, and Coding 13.3 AKI Criteria, Tubular Injury, and CKD Staging

14 Chapter 14: Diagnostic Precision in High-Impact Conditions

14.1 Respiratory Failure: Acuity, Evidence, and Sequencing 14.2 Heart Failure Phenotype, Acuity, and Hypertensive Combinations 14.3 Encephalopathy, Delirium, and Acute Cognitive Change

15 Chapter 15: Clinical Validation & Complication Discrepancies

15.1 Malnutrition Assessment, Severity, and Provider Documentation 15.2 Principles of a Compliant, Nonleading Query 15.3 Open-Ended, Multiple-Choice, and Yes/No Queries

16 Chapter 16: Query Mechanics & Direct Provider Collaboration

16.1 Electronic Query Systems, Templates, and Technology Oversight 16.2 Collaborating With the Appropriate Query Recipient 16.3 Capturing and Clarifying Query Responses

17 Chapter 17: Quality Indicators & Post-Discharge Clarification

17.1 Present on Admission Clarification and Selected HAC Rules 17.2 Clarifying Acuity, Cause, Site and Severity 17.3 Post-Discharge Query Opportunities and Limits 17.4 Managing Post-Discharge Query Workflows

18 Chapter 18: CDI Operational Dashboards & Quality Auditing

18.1 Departmental Metrics: Definitions, Calculations and Dashboard Use 18.2 Internal CDI Quality Audits and Reviewer Calibration 18.3 Query Trends: Understanding the Process and Provider Experience

19 Chapter 19: Benchmarking, Productivity & Data-Driven Workflow

19.1 Provider Documentation Benchmarking 19.2 External Benchmarking: CMI, Severity, Mortality and Length of Stay 19.3 Evaluating CDI Professional Performance 19.4 Using Data to Design CDI Workflow and Staffing

20 Chapter 20: Ethical CDI Standards & Regulatory Frameworks

20.1 Applying AHIMA Ethics to CDI Decisions 20.2 Responding to Financial Pressure and Upcoding Risks 20.3 Maintaining Competence and Professional Integrity

21 Chapter 21: Regulatory Compliance & Enforcement Landscapes

21.1 False Claims, Overpayments and Referral Laws 21.2 Regulatory Agencies, Review Contractors and Appeals 21.3 EHR Templates, Copied Text and Record Integrity

22 Chapter 22: Technology Risks & Second-Level Review Protocols

22.1 CAC, NLP and AI: Context, Oversight and Performance 22.2 Selecting Cases for Second-Level Review 22.3 Conducting and Closing a Second-Level Review

23 Chapter 23: Clinical Validation Queries & Risk Mitigation

23.1 Clinical Validation and Coding Clarification 23.2 Clinical Validation Queries and Denial Evidence 23.3 Detecting Leading, Biased and Unsupported Queries

24 Chapter 24: Noncompliant Query Remediation & Query Lifecycle Management

24.1 Query Remediation and Corrective Action 24.2 Query Timeframes, Aging and Measurement 24.3 Query Records, Retention and Evidence Preservation

22.2 Selecting Cases for Second-Level Review

Key Takeaways Explain This Topic AI

Second-level referral criteria, reviewer qualifications and timing are locally defined. Evaluate support concerns in the full record rather than apply one universal diagnostic or mandatory-referral cutoff.

Changing the only MCC does not necessarily remove every severity tier. Assess remaining qualifying diagnoses and re-run the actual grouper.

Identify the quality measure, program and version. PSI 04 is outside AHRQ PSI 90 v2025, and POA rules do not create a universal exclusion for every indicator.

Review mortality and complex procedures for accurate facts and applicable model inputs; do not seek a preferred ROM subclass, payment result or quality exclusion.

Different review authorities have different scopes. The April 2025 RAC Regions 3–5 SOW prohibits clinical validation in those RAC reviews while permitting specified other reviews.

Last updated: October 2026

Selecting Cases for Second-Level Review

A second-level review brings additional expertise to a documentation, coding or clinical-support question that needs closer examination. It can occur during the stay, before billing or retrospectively. The organization should define its referral criteria, reviewer qualifications, priorities and escalation process. There is no national requirement that every death, rejected query or single-MCC record receive the same review before discharge.

The purpose is accurate representation of the encounter. A review may support the existing documentation, identify a needed clarification, reveal an inappropriate query or identify a reporting error. It should remain open to each outcome. AHIMA's clinical-validation brief describes a second-level process as a possible organizational approach, particularly when ambiguity or recurring denial risks need deeper review. AHIMA Clinical Validation, 2023 Update

Define a referral by the question it must resolve

Possible local trigger Useful referral question Boundary

A diagnosis is the only qualifying CC or MCC Is the diagnosis supported and reportable, and is the grouping correct? Do not look for substitute diagnoses merely to preserve payment

A quality-indicator flag appears Were the correct data and applicable measure rules used? A flag is not a finding of preventable harm or an instruction to secure an exclusion

An inpatient dies or a case has an unexpected risk classification Does the record accurately describe the clinical course and applicable model inputs? Do not seek a predetermined mortality-risk subclass

A complex procedure or duration affects reporting Do the operative report, procedure details and timeline support the assigned code? A payment estimate does not establish the procedure or duration

A documented diagnosis has unclear or contradictory support Is clarification needed after review of the full clinical picture? A screening threshold is not an automatic diagnosis or deletion rule

A query or provider response raises a concern Is the query appropriate, and what question remains unresolved? A refusal or “unable to determine” response is not itself evidence of misconduct

Targeted referral and sampling serve different purposes. A high-risk workqueue can prioritize known concerns; an appropriately designed sample can reveal issues that the trigger logic misses. Choosing one does not eliminate the value of the other. Set priorities using the question, consequence, timeliness and available expertise, with a route for manual referrals when software does not recognize the issue.

Review a single-CC or single-MCC case without assuming the result

“Fragile DRG” is an informal operational term for a case whose grouping depends on one qualifying secondary diagnosis. The actual effect of changing that diagnosis depends on the DRG family, remaining diagnoses, exclusions, procedures and other grouper inputs.

In the FY2027 v44 heart-failure-and-shock family, MS-DRG 291 is with MCC, 292 is with CC and 293 is without CC/MCC. Consider an illustrative case already appropriately assigned to this family: its sole qualifying MCC is removed after proper clarification, but another qualifying CC remains. With other grouping factors unchanged, the CC tier remains relevant; the case does not automatically fall to 293. Re-run the applicable grouper using the final supported information. CMS FY2027 v44 definitions, Appendices A and C

The review should ask why the diagnosis is documented, what supports it, whether any conflict needs clarification and whether reporting rules are met. It should not attempt to create “comorbidity redundancy.” Each additional diagnosis must independently satisfy the applicable requirements. National approximate dollar amounts or relative weights cannot establish the actual payment loss for an individual hospital claim. FY2027 ICD-10-CM guidelines, Sections I.A.19 and III

Treat a quality flag as a request to verify the measure

For each flag, establish the measure, reporting program, version, population and data period. Then review numerator and denominator logic, exclusions, codes, POA indicators and procedure dates as applicable. Keep the clinical assessment, coding decision and measure calculation distinct.

For example, PSI 04 is not a component of AHRQ PSI 90 v2025 . A referral can still concern PSI 04, but it should not call that review a PSI 90 component review. PSI 11 likewise has several diagnosis/procedure pathways and timing rules; it is not simply “postoperative ventilation of at least 96 hours.” Review the actual specification rather than a shortened workqueue label. AHRQ PSI 90 v2025 composite guide ; PSI 11 v2025 specification, pages 1–3

POA is determined relative to the inpatient admission order, with the applicable rules for conditions developing during outpatient services before that order. It is not determined simply by arrival at the hospital or the date a copied sentence was entered. U means insufficient documentation; it does not prove a condition was acquired in the hospital. A Y indicator is not a universal statutory exclusion from every PSI. Apply the particular measure's rules and clarify unresolved documentation neutrally. FY2027 POA guidelines

CMS's HAC Reduction Program uses CMS PSI 90 alongside specified infection measures. Its 1% payment reduction concerns applicable hospitals whose Total HAC Score falls in the worst-performing quartile; a single flagged case does not automatically impose that reduction. Do not transfer a measure or penalty rule to the separate Hospital VBP Program without checking that program and year. CMS HAC Reduction Program

Review mortality and complex procedures for accuracy

An expired patient's record may warrant closer review of the course, diagnosis evolution, admission timing and completeness. The outcome does not authorize a search for diagnoses designed to raise expected mortality. Solventum APR-DRG SOI/ROM subclasses are a particular methodology; they are not interchangeable with all CMS mortality measures, rating systems or registries. CMS publicly reports condition- and procedure-specific 30-day risk-standardized mortality measures. Determine the actual model before asserting that a diagnosis, DNR status or palliative-care code changes its result. A low-risk classification followed by death is a review signal, not proof of poor care. Solventum APR-DRGs ; CMS outcome measures

For a procedure referral, identify the exact uncertainty: objective, body part, approach, device, qualifier or duration. Read the operative and relevant respiratory records and apply the current PCS definitions and guidelines. The ventilation category for greater than 96 consecutive hours differs from 24–96 hours; exactly 96 is not greater than 96. A workqueue flag does not establish ventilation hours or an MS-DRG, and an ECMO label alone does not establish every grouping input. FY2027 PCS tables

Refer clinical-support concerns without converting them into automatic denials

Malnutrition, sepsis, respiratory failure, kidney injury and encephalopathy can raise difficult questions, but the concern must be explained in the actual case. Use the relevant clinical lesson and source rather than applying a universal list of mandatory diagnostic cutoffs.

For example, albumin and prealbumin alone do not diagnose malnutrition. Their presence can prompt review of the provider's assessment and the nutrition record; their absence or an incomplete short vignette does not itself rule malnutrition out. Similarly, a treatment response, oxygen flow rate or one laboratory value should not replace the complete clinical picture. The reviewer identifies the concern and supports appropriate clarification; the responsible provider exercises diagnostic judgment. ASPEN visceral-protein position paper ; 2026 query guidance

Use the actual review authority when analyzing denials. CMS's April 2025 Regions 3–5 RAC statement of work distinguishes coding validation and medical-necessity review from clinical validation and prohibits clinical validation in those RAC reviews. Do not treat every commercial clinical-validation denial as an example of the same RAC authority. CMS RAC Regions 3–5 statement of work, pages 13 and 24

Finally, evaluate the original query before escalating a provider interaction. A correct response may be that the diagnosis cannot be determined or that the existing record already answers the question. Use the organization's compliant follow-up process for a genuine unresolved issue. A second-level reviewer or physician advisor can help assess the query and communication; the role does not authorize pressure for a preferred diagnosis. 2026 query guidance, provider collaboration and multiple-query sections