Clinical documentation tells the story of why the patient sought care and what happened to the patient throughout the encounter.  The physician must clearly indicate the rationale and procedures performed to arrive at a primary diagnosis/chief complaint, as well as the determination of secondary diagnoses that affected the method by which treatment was provided.  When the physician uses language that matches the criteria for code assignment as spelled out in the Official Coding Guidelines, then the coder can assign the appropriate diagnosis and procedure codes.

Thus, documentation provides the basis for reimbursement, while also communicating whether the proper treatment protocols were followed as per payer guidelines and the provider's utilization manaegment policies.  Improper documentation has far reaching consequences, and therefore it is necessary that the coding staff query the physician whenever the episode of care has not been adequately communicated in the medical record through the physician's notes, reports, and discharge summary.

Of course, constant physician queries slow coding productivity, delay billing, and impinge on the doctors' time.  Codebusters Clinical Documentation Improvement Specialists can work with your physician staff to identify any problems or deficiencies identified through an audit of your encounters.  We provide patient but effective training so that your clinical staff and coders fully understand the reasoning behind our recommendations.  In addition, we also can provide full time CDI Specialists who can work with the doctor real time, either on the floor or through a remote connection to the EHR.