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Victor Freeman, M.D., Regional Medical Director for Nuance Healthcare Solutions, spoke at a recent CME event on the importance of clinical documentation for every provider.
Here are 10 tips from Dr. Freeman’s presentation and a panel discussion with LG Health/Penn Medicine providers:

  • Remember: Clinical documentation drives coding – and coding drives payment. If you don’t take documentation seriously, it will come out of your pocket.

  • Provider pay is increasingly tied to performance. Poor performance ratings sometimes reflect weak documentation more than the quality of care delivered.

  • Make sure you get credit for the true severity of your patient’s conditions. Be specific. For example, there is a big difference between “thin” and “severe protein malnutrition.”

  • Be thorough. Document all diagnoses associated with your patient. Capturing secondary diagnoses allows for risk and severity adjustments, which help to more accurately reflect your patient’s condition -- and the quality of your performance.

  • It’s not just about you. Failure to accurately capture all of your patient’s diagnoses also affects performance ratings for your group and hospital.

  • Now that the ICD-10 transition is complete, expect increased scrutiny on documentation. Good, thorough documentation is your best protection.

  • Proving medical necessity is essential. A code isn’t enough. You must explain why the patient needs that particular procedure at that particular time.

  • Make sure you can support every diagnosis on a patient’s chart, using clinical criteria or a clinical evaluation. This will help you defend the chart in the case of an audit.

  • Don’t stretch the truth. Exaggerating the severity of a patient’s condition will get you in trouble. Physicians do go to jail for fraudulent billing.

  • The Clinical Documentation team is not here to police you. They are here to help you be successful. Questions? Contact Jean E. Banzhof, MSN, RN, Manager, Clinical Documentation Improvement, 544-4426 or

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