Physician Advisor’s Corner: Clinical Documentation

Premier Pulse     July 2020

Maigur_HS_350x350By Andrew Maigur, MD

It’s imperative as physicians to realize that Clinical Documentation Integrity is a quality initiative. Accurate, high-quality clinical documentation improves communication, increases recognition of comorbid conditions that are responsive to treatment, validates the care that was provided, and shows compliance with quality and safety guidelines. As a fellow physician, I am positive that I would not have to persuade you to want to take excellent medical care of your patient.

Here are four reasons why you should be invested in optimal documentation:

  • It is in the patient's best interests. We owe our patients an accurate medical record.
  • It is in the provider's best interests. Not just the hospital's, but your quality metrics (LOS, readmissions, SOI-Severity of Illness score, ROM-Risk of Mortality score, PSI-Patient Safety Indicator, post-op complications) are also derived from observed–to–expected risk–adjusted metrics (abstracted from coded data). Your quality measures are publicly available for review on Medicare’s Physician Compare ( and may guide potential patients’ choice of provider.
  • It is also important that physicians understand the process of audits and denials and the financial impact on the hospital. At this time, most physicians have not felt any repercussions from a recovery audit contractor (RAC) denial, but the impact on a hospital is very tangible. Not surprisingly, the top 10 RAC-denied diagnoses are often similar to the top 10 queried diagnoses. Hence, good documentation done concurrently will only help to improve the outcome of a RAC audit. CMS issued Transmittal 541 that allows Medicare Administrative Contractor (MACs) and Zone Program Integrity Contractors (ZPICs) to deny “related claims.” This means when the facility receives a denial if an admission is found to not be medically necessary, they can also deny the corresponding physician claims.
  • It is in the hospital’s best interests. The hospital is being judged by certain quality measures, and rewarded or penalized for, in turn. If our hospital looks substandard on Hospital Compare ( patients and payers may avoid our services. If our sites of care look bad in value-based purchasing, they may lose money. No margin, no mission.

Some of you might think, “I don’t care about the hospital’s reimbursement.” I would ask, is it fair that the hospital provides state-of-the-art care for your sick patients and incurs soaring costs of care but does not receive the appropriate reimbursement? Absolutely not!

I would ardently encourage you to consider CDI and Coding as your allies to facilitate accurate, codable, clinical documentation to reflect the excellent care you provide to our patients!

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