Leveraging medical record documentation for medical coding accuracy and revenue integrity

You’ve probably heard the adage, "If it’s not documented, it didn’t happen." The idea is simple: The medical record tells the patient’s story. When a healthcare provider fails to document what they did and why, it becomes impossible to prove what actually happened during a patient encounter. 

As you can imagine, healthcare documentation is important for all kinds of reasons — not only to recap the patient visit. Good documentation protects providers against lawsuits; promotes high-quality, safe patient care; enables smooth transitions of care; and builds patient engagement and trust. 

However, in today’s highly regulated payer environment, one of the most important roles of medical record documentation is this: It ensures accurate medical codes that pave the way for revenue integrity. In other words, without healthcare documentation, you won’t get paid.

In this article, we’ll explain how medical record documentation impacts medical code assignment; identify what constitutes good, compliant documentation; and provide tips on how to improve your documentation.

The diagnosis, procedure, and supply codes that healthcare providers and medical coders report to payers are based on documentation in the medical record. Key terms and phrases in that documentation are translated to medical codes required for healthcare claim submission. 

However, these translations are anything but straightforward. That’s because there’s a whole host of rules (e.g., coding conventions, payer requirements, CPT coding guidelines, ICD-10-CM coding guidelines, and more) to follow — and the rules change often.

One rule that doesn’t change is this: The more specific the documentation, the better. Why? Accurate and complete medical record documentation leads to more specific medical codes that decrease denials and promote revenue integrity and timely payment.

Unfortunately, many providers struggle with healthcare documentation. In some cases, providers may not know what payers require. 

In other cases, physicians may know what they need to document, but they may overlook certain elements because they’re pressed for time. Insufficient documentation accounted for 32.4% of improper payments for evaluation and management (E/M) services in 2022. 

Documentation is also a commonly-cited source of administrative burden and physician burnout, and many physicians feel that documentation time is inappropriate and takes time from patients. 

Compliant documentation tells the patient’s story. That includes details such as the reason for the encounter (with as much diagnostic specificity as ICD-10-CM allows), physical exam findings, relevant history, assessment and plan, rationale for ordering diagnostic and other ancillary services, total time spent with the patient, and other important details. 

Documentation must be clear, concise, legible, signed, and dated. For Medicare, it must also meet National Coverage Determinations and Local Coverage Determinations. Ensuring compliance may require specific documentation as well as the assignment of certain ICD-10-CM and CPT/HCPCS codes based on that documentation.

Here’s another great source for compliant healthcare documentation: The National Committee for Quality Assurance’s (NCQA) documentation guidelines that promote consistent, current, and complete medical record documentation for quality patient care. When healthcare providers follow these guidelines, they inevitably provide medical coders with the information they need to assign accurate and complete codes.

Looking for another source to improve Medicare documentation? Check out this July 2023 CMS Medlearn Matters article (MLN 909160) that outlines several common errors related to insufficient documentation. These include the following:

In MLN 909160, CMS specifically cites the following services as being at risk for insufficient documentation errors:

Note that new documentation guidelines for E/M office visit codes took effect January 1, 2021 allowing physicians and medical coders to assign these codes based on total time spent with the patient or medical decision-making.

In an era of value-based payment models, documentation must also increasingly convey patient risk through ICD-10-CM hierarchical condition category (HCC) codes. HCCs are coexisting, comorbid conditions as well as chronic conditions that affect the patient’s health status concurrently across the continuum of care. 

The CY2024 CMS-HCC model classifies the approximately 74,000 ICD-10-CM diagnoses codes into 266 CMS-HCCs, 115 of which are included in the 2024 payment model.

If you’re looking for additional guidance on best practice documentation for Medicare risk adjustment, take a look at CMS’ Risk Adjustment Data Validation (RADV) audit guidance. RADV auditors perform retrospective audits to confirm whether any diagnoses submitted by Medicare Advantage Organizations for risk adjustment are supported in the enrollee’s medical record. RADV audit guidance is helpful because it gives you a sense of what auditors are looking for in terms of medical record documentation so you can tailor your practices accordingly. 

Although medical codes for social determinants of health (SDOH) aren’t required, addressing and reporting them may help physicians justify higher levels of E/M codes. These Z codes can also help healthcare providers enhance quality improvement initiatives, close clinical care gaps, improve outcomes, and lower costs. 

In terms of medical record documentation for SDOH, here’s what you need to know:

There are several ways to improve healthcare documentation. Consider the following:

It all starts with healthcare providers who need to understand payer-specific documentation requirements. What may suffice and meet medical necessity criteria for one payer may not work for another. 

Also, keep in mind that not all payers follow Medicare. Medical coders can be a powerful knowledge source in terms of training clinicians on how to document appropriately. Coders can also develop clinical documentation improvement cheat sheets and work with electronic health record (EHR) vendors to enhance documentation templates and other tools.

Giving patients access to their own medical records through the patient portal can be a powerful way to avoid documentation errors and omissions. Encourage patients to validate the accuracy of their information and ensure there is a process in place for requesting medical record amendments. 

Many of today’s EHRs provide documentation tools, templates, and resources designed to help physicians save time while also providing high-quality documentation. If you’re not sure what your vendor offers, inquire. 

Sometimes, it’s a matter of simply ‘turning on’ the functionality or developing best practices around its use. For example, if you decide to permit copying and pasting (which can save physicians considerable time), be sure to provide clear parameters around when and how to use it. That way, you avoid note bloat that can lead to denials and even compromise patient safety and care quality.

Take a small sample of claims and look at what information healthcare providers document. Does it justify medical necessity? Provide enough information for accurate medical code assignment?

Where are the gaps? What can you do to provide additional physician education to increase your clean claim rate? 

If claims are denied, what is the reason? What slipped through the cracks, and how can you avoid that same mistake in the future?

Querying physicians for clearer, more specific documentation can improve the accuracy of medical coding. For example, medical coders should query when a physician does not bring the results of a lab or imaging test ordered as part of the face-to-face visit into the note.

They should also query when a diagnosis is on the active problem list for the visit, but the physician doesn’t document addressing or assessing it as part of the visit. 

Other reasons to query? Physicians document clinical indicators in the visit note but don’t document an accompanying diagnosis, physicians assign a code without indicating they addressed or assessed that condition during the visit, or there’s contradictory information in the visit note.

Medical record documentation directly affects the medical codes that healthcare providers report. These codes, in turn, affect everything from payment to patient financial responsibility to research and more. Improving the accuracy and completeness of healthcare documentation also improves the accuracy and completeness of the coded data.