Like a broken record, health information management (HIM) professionals have repeatedly warned physicians and other clinicians about the importance of medical-record documentation by saying, “If it’s not documented, it wasn’t done!”


With advancements and challenges such as the evolution of electronic health records (EHRs), complex reviews by recovery audit contractors (RACs), and implementation of clinical documentation improvement (CDI) programs, it may be time to change our tune to “if it’s documented, it better have been done!”


First and foremost, the purpose of medical-record documentation is to support patient-care activities. Of course, this same documentation is also vital to other activities such as coding and reimbursement, level-of-care determination, quality and core-measures reporting, medico-legal support, and healthcare statistics.  Hospitals and physicians continue to be challenged by the task of documenting a complete and accurate medical record that supports both the medical necessity of admission and code assignments in an efficient and effective manner.


The Challenges of Electronic Records


With federal and state incentives to install and meaningfully use EHRs, hospitals have been transitioning from paper to hybrid or fully electronic records. In the paper-record world, an inpatient record had a definite beginning and end, just like reading a book, but the electronic inpatient record is not so static. EHR systems allow for certain data elements, such as allergies and medication lists, to be continuously updated, which makes it challenging to get a snapshot of information for a particular date and time.


Some EHR systems also allow for previously recorded information from other encounters (inpatient, outpatient or even the physician’s office) to be pulled forward into a new visit record, which makes it challenging to know what is relevant to the current encounter.  The use of templates, canned text, and cut-and-paste features can be convenient methods for capturing physician documentation but can lead to large volumes of information being collected without a lot of added value.


For example, a dictated history and physical (H&P) may result in a two-page transcribed document while a templated H&P may result in an 8-10 page report without added quality in the documentation.


Another challenge with the EHR requirements for inpatient records is the addition of a problem list to capture current, chronic, probable and/or resolved problems (i.e., diagnoses) as discrete data elements. To accomplish this, EHR systems link the problems to ICD-9-CM or SNOMED codes to allow the physicians to select from a list of problems versus having to enter this information as free text. The code descriptions associated with the problems can create challenges for physicians to select the correct one.


For example, a physician may intend to record a remote history of a myocardial infarction and actually record what appears to be a new acute myocardial infarction (MI). An up-to-date problem list could be a very beneficial addition to the inpatient record if properly implemented and maintained.  The current state of problem lists at many hospitals makes it challenging to refer to this information for code assignment or other purposes.


Importance of Documentation Grows


Early efforts of the RACs for complex reviews were primarily focused on validation of DRG assignment.  Most recently, the majority of published issues for complex reviews have been related to medical necessity of inpatient admissions. This puts the reimbursement of an entire inpatient claim in jeopardy.


According to the Medicare Benefit Policy Manual related to coverage of Part A inpatient services, “The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs. Factors to be considered when making the decision to admit include such things as the severity of the signs and symptoms exhibited by the patient and the medical predictability of something adverse happening to the patient.”


Physician documentation should focus on documenting these elements to paint a picture of the patient’s clinical findings and the plan for the hospitalization. A good narrative note from the physician that includes the clinical rationale for admission can be essential to justifying medical necessity.  Physicians also should consider the discharge summary as their last opportunity to include information to support the need for inpatient admission, confirm or deny diagnoses, and/or to identify any uncertain conditions that had an impact (i.e., work-up, resources, treatments, and planned follow-up) on the hospitalization.


In addition to improved documentation, hospitals should confirm that they are meeting all of the elements in the utilization review section of the Medicare conditions of participation (CoP) (Title 42, Code of Federal Regulations [CFR], section 482.30). Effective case management, utilization review and physician-advisor functions are vital to a hospital’s success in assigning the appropriate level of care.



Making Improvements


In the early days of the DRG-reimbursement system, coders were confident in assigning an ICD-9-CM code if a physician documented the diagnosis anywhere in the medical record without much regard to clinical indicators such as signs and symptoms, test results, and/or treatments rendered. We trusted that if it was included in the physician documentation, it was safe to code.


With the increase in DRG validation and coding audits being done by third-party payers, including the RACs, it’s time to reacquaint ourselves with the ICD-9-CM Official Guidelines for Coding and Reporting.  Of particular importance is section III of the guidelines related to the assignment of additional diagnoses.


Audit activities typically target cases that are vulnerable because only one MCC or CC is present. This gives the payer an opportunity for a DRG change if it can overturn that one diagnosis.  During DRG-validation audits, when a case lacks clinical evidence that a diagnosis was present, even though the physician documented it, some third-party auditors are denying these as “clinical denials” versus technical coding denials.


To assist in capturing and clarifying medical-record documentation during inpatient encounters, many hospitals have effectively implemented CDI programs. In addition to improved documentation to support patient care and case-management activities, hospitals with CDI programs benefit from increased specificity in their coded data and DRG assignment. These efforts have led to a positive change in documentation habits for many physicians (i.e., specifying congestive heart failure as acute, chronic, systolic and/or diastolic) but can also lead to the routine documentation of diagnoses that may not necessarily be clinically supported in every case (i.e., acute blood loss anemia).


According to AHIMA’s Guidance for Clinical Documentation Improvement Programs, typical situations addressed by a query include the following:


  • Presenting clinical indicators of an undocumented condition
  • Requesting further specificity or the degree of severity of a documented condition
  • Clarifying a potential cause-and-effect relationship
  • Addressing present-on-admission issues.


If medical-record documentation is still not clear post-discharge for the purposes of final coding and DRG assignment, an effective query process should be in place. Although it could have a bearing on the final DRG assignment, the decision to query post-discharge or even wait for a discharge summary before final coding varies from facility to facility based on policies and procedures and the impact on the unbilled accounts receivable.




In the midst of all these challenges, we can see even more on the horizon such as the October 2013 conversion to ICD-10-CM and PCS, ongoing changes impacting inpatient reimbursement (i.e., pay for performance, pre-payment reviews, readmission reduction program), and the continued advancement of the EHR including health information exchange (HIE) between caregivers.


Efforts to improve medical-record documentation should continue to be geared towards capturing complete and accurate information that is specific and pertinent to the patient’s current encounter – most importantly for the care of the patient but also to justify the proper reimbursement for the level of care provided.  Medical records are under more scrutiny than ever before.  The need to dot our I’s and cross our T’s has never been more important.



About the Author


Sandra Routhier is a senior healthcare consultant with MedLearn, Inc., a Panacea Healthcare Solutions Company, St. Paul, MN. Sandy has more than 25 years of professional experience in HIM, Revenue Cycle, Utilization Management and Information Systems.


Contact the Author:


To comment on this article please go to


Post-Payment Probe Reviews’ Impact on RAC Investigations


Share This Article