Why specificity is critical in clinical documentation

When it comes to billing and reimbursement for health systems, getting paid can be tough. But clinical documentation using granular terminology can help.
When it comes to billing and reimbursement for health systems, getting paid can be tough. But clinical documentation using granular clinical terminology can help.

Ask most anyone who works on the financial side of healthcare, and they’ll likely tell you that it can be a struggle to get paid – no matter if you’re in the billing department of a hospital or an health information exchange (HIE) providing data analysis for an entire health system. While the money of medicine is multifaceted, a lack of specificity within medical records can cause problems across the board.

That’s mainly because it’s easy to lose or omit specificity during an initial patient encounter – an issue that is then compounded when translating a clinician’s notes into standardized code sets and then transferring the information across systems. When the precise details, granular insights, and unique nuances of the patient’s problems and procedures are lost, there’s a ripple effect throughout an institution and among its partners. As the losses compound, healthcare players have to manage the loss of not only important data, but also appropriate financial return and increased patient risk.

With information documentation and transfer being so key to the success of any health system, understanding how it can go awry and ways to minimize the fallout are skills that will continue to pay dividends.

Read IMO’s whitepaper, Specificity is the new black: A guide to getting greater reimbursement to learn about five ways data specificity gets diminished in a healthcare setting, along with solutions to help mitigate its negative effect on the bottom line.

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