Note from the Associate Editorial Director: Lack of response to documentation request hurts physicians

by Melissa Varnavas

CDI professionals your hard work is paying off. I just read an article in the Physicians News Digest that outlined some of the documentation truisms CDI specialists have touted for some time.

“With heated efforts focused on E/M services, what should providers do in the face of this scrutiny?” asks article author Michael Calahan. “The first order of business,” he says, ” is to ascertain which audit findings yield valuable opportunities for clinical documentation improvement as well as coding and billing fortification.” (Emphasis added.)

Furthermore, top on Calahan’s list of solutions to nonpayment concerns and audit results is… wait for it… respond to requests for additional documentation.

“The number one reason for physician and nonphysician practitioner (NPP) services being downcoded or denied by auditors is non-response to Additional Documentation Requests (ADRs).”

Calahan actually is referring to federal auditor’s requests for additional documentation but the implications of his assessment can certainly be applied to inpatient clinical documentation improvement efforts—why wouldn’t it?

A quick read through his article, “Lessons from Federal Audit Initiatives: A Top 10 Survival Guide,” may yield some additional teaching tips for CDI specialists struggling with E/M documentation compliance. At the very least the article illustrates that CDI specialists aren’t the only ones thinking about the importance of documentation improvement these days.

Editor's note: Varnavas is the associate editorial director of ACDIS. Contact her at mvarnavas@acdis.org.