Introducing a Clinical Documentation Specialist to Improve Coding and Collectability on a Surgical Service

Inadequate electronic medical record (EMR) documentation remains a significant source of revenue loss. The Department of Surgery in a trauma and tertiary care teaching hospital developed a revenue optimization initiative for inpatients on general, vascular, and trauma surgery and surgical intensive care unit services to enhance clinical documentation and increase revenue capture.

Clinical documentation management program included six trained clinical documentation specialists (CDSs), five physician assistants (PAs), directors of health information management (HIM), and two surgical champions. Lean methodology was applied to develop a coding and documentation program wherein trained CDS polled ICD-10 codes in the surgical EMR for accuracy in diagnoses documentation. An opportunity for improved documentation prompted query generation for a specially trained PA review. Physician assistant adjusted EMR documentation according to query to more accurately describe high impact diagnoses. Outcomes included PA query response rate, potential revenue opportunities, validated revenue gains, and missed revenue opportunity.

Twelve thousand EMRs were queried in the study interval. $2,206,620.16 in validated revenues were realized. Interestingly, we identified $1,792,591.91 in potential opportunities and $65,097.30 in lost opportunities. Query response rate increased from 17% to 94.7%.

The authors demonstrate a concentrated Coding and Documentation Program involving CDS, and Surgical PAs results in significant revenue gains for an inpatient surgery service in a public hospital.