Frequently Asked Questions

How does documentation impact hospitals and providers?


  • Documentation supports coding which is the basis of correct revenue and reimbursement. Otherwise a hospital could be losing revenue.
  • Documentation is necessary for  complying with quality measures.
  • Quality information supports care management and making sure protocols are followed.
  • Driving appropriate coding and DRG assignment for accurate reimbursement
  • Improving accuracy of patient acuity levels – impacting relative weight, severity and ultimately CMI
  • Reducing compliance risks
  • Providing accurate data for quality and outcome measures (specifically observed to expected mortality indices and adjusted length of stay)
  • Reducing coding turnaround time and CDI work loads
  • Decreasing coding queries to providers – reducing provider burnout and improving clinical efficiencies

Documentation is critical for patient care, not only because it validates the care that was provided, but also because it shares key data with subsequent caregivers and optimizes claims processing. As such, clinical documentation improvement (CDI) programs are important to any facility that recognizes the necessity of complete and accurate patient documentation.

But even as successful CDI programs become more prevalent in hospitals and health systems across the country, many physicians still don’t really understand the importance behind it, says Wendy Vincent, national practice director, strategic advisory group at Beacon Partners, a Weymouth, Mass.-based consulting firm. Engaging physicians to improve their clinical documentation is critical to the success of the entire healthcare organization, yet getting physician buy-in for this strategy remains difficult, notes Vincent, who sees this problem occurring for many of her clients.

At the core of the problem is that physicians are extremely busy, Vincent says, and because of that, they’re not connecting the dots on clinical documentation. As a result, Vincent advises that the best way to deal with their demanding schedules is to engage them in a positive way, train them, and give them time to see the relevance in improving their documenting. “A good CDI program has key executives engaged and transparent, with physician leadership all the way up to the CMO,” she says. “The organization needs to embrace it.”

What is the ICD-10 Effect?


Documentation practices have been considered by many to be the top driver for ICD-10 success, given that clinical documentation must meet the level of coding specificity and granularity required to: achieve optimal reimbursement; meet all regulatory and reporting requirements; and accurately reflect the level of care provided. Vincent says that when she talks to clients across the country, one of the key things she needs them to takeaway is that a good CDI program and good documentation is a fundamental critical step to achieving a successful ICD-10 implementation.

“Whether it’s right or wrong, the delays to ICD-10 have impacted the industry once again,” Vincent says. “When federal regulations are delayed or postponed, many of our clients stop the work and push it off. We say that if you’re going to stop and delay your ICD-10 work, let’s at least go ahead and talk about how you can fix your documentation and your coding, and optimizing that, because that’s one more step that will bring them closer and aligned to being in good shape to when you do have to cross over,” she says.

Certainly, some might see the delay of the ICD-10 compliance date as a “silver lining,” in that providers can take advantage of the delay to improve their clinical documentation skills. But Vincent says that for her clients, the delay is perceived as both positive and negative. “It’s seen as a positive because it’s another thing they don’t have to deal with, but also a negative to some because they have already spent the dollars, they’re ready, and they’re concerned about the potential of not moving ahead at all. But I don’t think that will be the case—I believe we will move forward,” she says.

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