Focus on Clinical Documentation to Improve Coding and Audit Results

by  Betty Stump, MHS, RHIT, CPC, CCS-P, CPMA, CDIP
June 29th, 2017

Auditors spend their day surrounded by the end product of the health care process. Those CPT, HCPCS and ICD-10-CM codes generated as a result of services provided to the patient. Our work is focused on determining if those codes have been correctly assigned based on the content of the medical record documentation. All too often however, auditors consider deficiencies and errors to be an error of coding when in fact, the errors arise from the clinical documentation. Just as a kitchen can only produce tasty, delicious meals when the ingredients available are fresh, wholesome and high-quality, healthcare providers can only generate accurate, specific and correct codes when the quality of the documentation is at its best. It's important for auditors to both understand and educate providers not just on how to improve their coding, but rather how to improve their clinical documentation.

The idea of 'clinical documentation improvement' (CDI) comes from inpatient hospital care. Generally, specially trained nurse reviewers or health information management specialists are known as clinical documentation specialists (CDS's). They work to ensure the hospital medical record documentation is clinically accurate and specific and fully captures clinical severity of illness (SOI), complications and comorbidities (CC), risk of mortality (ROM), and any condition present at the time of admission (POA). Hospitals have quickly come to recognize the value of documentation that is accurate and clinically appropriate in ensuring appropriate billing and to assist in preventing unnecessary claim denials. Auditors working in physician offices and other ambulatory care settings should look to CDI as a method to improve the quality and accuracy of the physician's coding. Physicians can be frustrated when faced with audits deemed as 'failing' and can be difficult to engage in discussions to improve coding quality. By focusing on clinical documentation, auditors can help reduce physician frustration and support quality patient care by ensuring clinical information is complete and compliant from the start. Furthermore, shifts in modern healthcare with increasing focus on medical necessity, quality, and outcome measures make it an opportune time for auditors to become champions of clinical documentation improvement.

A 2016 article published in the AHIMA Journal sums up the idea of CDI in the physician office with the following statements:

Documentation quality begins in the outpatient setting. Physicians who document well in their practices help establish a baseline for patient severity and justify medical necessity for inpatient services. Quality documentation enhances outcomes and ensures accurate revenue. Now is the time to evaluate needs, build partnerships, and begin the important task of improving physician practice documentation.

It's time for auditors to move beyond the codes and work together with healthcare providers to improve the clinical record so the services rendered are accurately, compliantly, and correctly reported.

Focus on Clinical Documentation to Improve Coding and Audit Results. (2017, June 29). Find-A-Code Articles. Retrieved from

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