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Optimization of Documentation- Is This the Right Terminology?

January 20, 2018

Optimization of Documentation- Is This the Right Terminology?


Optimization of documentation, is this the right terminology to be utilizing in a conversation regarding documentation improvement and how do you define “optimization of documentation?” DRG were introduced in 1982 as a prospective payment system to contain and curtail excessive Medicare costs associated with Medicare beneficiary hospitalizations. The advent of the DRG system served as a primer for DRG Optimization consulting companies that sprung up like dandelions in the spring, popping up everywhere. These organizations utilized techniques of documentation and coding, often manipulating the clinical truth of documentation in the record to optimize the DRG and thus reimbursement. As the government and its contractors clamped down on illegitimate hospital gains from documentation excesses rooted in DRG maximization, implementing more strict guidelines and regulations governing documentation, coding and billing, attrition took its toll on these companies with many not surviving. The firms still standing evolved into legitimate entities offering clinical documentation improvement services with new firms throwing their hat into the ring recognizing the opportunity to provide a valuable service while earning a reasonable profit. As time progressed the clinical documentation improvement industry and the entire suite of firms servicing and supporting CDI activities have metamorphosed into a mindset of “clinical documentation optimization” driving fundamental structural processes with optimization of revenue as the ultimate achievable outcome.


I am certainly not philosophically against optimal reimbursement as a matter of business principles and ethics of business, after all healthcare is a business that requires positive cash flow and positive net financial margins to survive.  An overreliance on optimization of documentation as a means to an end of optimal reimbursement may not coincide with the good of the patient and the honest communication of patient care. Optimization of documentation taking literally and on face value can lead to downstream problems and potential compliance and other issues and concerns. An unrelenting focus upon optimization of documentation through the clinical documentation improvement specialists query process for CCs & MCCs has the strong tendency to documentation of diagnoses that are ripe for third party payer refutation leading to clinical validation denials as well as very costly MS-DRG down-codes with legitimate loss of hospital revenue. The common denominator in clinical documentation optimization contributing to potential loss of net patient revenue and compliance issues is weak or devoid clinical documentation of the clinical facts, clinical information and context of the case in support of the diagnoses of record used in ICD-10 codes and MS-DRG assignment. A medical record that inadequately tells the patient true story, accurately reflecting and reporting the patient encounter that describes, shows, tells and communicates the care provided and why is open to possible allegations of overcoding even if not done intentionally. Optimal clinical documentation does not necessarily correlate with optimal compliant coding, instead it equates to swinging for a homerun when all that is needed is for the batter to get on first base.




Effective clinical documentation is the preferred terminology that drives clinical documentation improvement initiatives in the