When working as a medical coder you might hear the phrase “If it was not documented, it was not done.” This is an important concept that medical coders need to understand to be successful. The medical record for each patient contains the clinical documentation provided by the physician.
There are many reasons why clinical documentation is important. Here are a few:
1) Critical for patient care
2) Serves as a legal document
3) Provides information for quality reviews
4) Validates the patient care provided
5) Reduces the number of claims that need to be re-submitted
6) Impacts coding, billing, and reimbursement
Clinical documentation should be complete, accurate, legible, timely, concise, clear, and patient centered. In order to accomplish this, each organization should have a clinical documentation improvement (CDI) program. A successful program leads to better communication with providers, decreased physician queries, increased reimbursement, and fewer denied accounts.
Each organization should have a clinical documentation specialist to oversee this program. The role of this individual is to monitor the clinical documentation so that is accurately demonstrates the intensity of service and level of care provided for the patient. The CDI specialist is also responsible for reviewing medical records for accuracy and compliance and providing ongoing clinical documentation education. This role will be even more important when ICD-10 is implemented because of the increased number of codes as well as the increased specificity of the codes.
The goal of an clinical documentation improvement program as it relates to ICD-10 coding is to ensure that the clinical documentation supports ICD-10 coding specificity with minimal impact on the productivity of medical coders. The more accurate and specific the documentation is the less time the medical coders will need to spend clarifying the documentation with the physicians.
Remember “If it was not documented, it was not done.” If it wasn’t documented it cannot be coded.