Documentation tips for pulmonary medicine: implications for the inpatient setting

Abstract

Clinical documentation improvement is an important aspect to achieve top performance. Clinical documentation in a patient's record includes any and all documentation that relates to the care of the patient during the patient's stay or encounter at the hospital. Documentation is key to accurate clinical coding, validating length of stay, resource utilization, physician profiling, case management, severity of illness, risk of mortality, quality management, risk management, clinical outcomes, critical pathways, regulatory compliance, Joint Commission accreditation, managed care, and reimbursement. Good documentation minimizes coding errors, reduces claim denials, and optimizes reimbursement. Implementing quality improvement strategies that make documentation and coding an organizational priority can positively influence operations, services, and revenue. Other external and internal coding audits show that the cause of improper coding is due to lack of proper physician documentation to support reimbursement at the appropriate level. The purpose of this article is to provide tips for documenting pulmonary diagnoses that not only would ensure appropriate reimbursement but also would accurately represent the severity of a patient's condition.