March 2025: Beyond Heads & Beds
Mastering Medical Documentation Audits: Success, Risk Mitigation, and Revenue Protection
Beyond Heads & Beds: Quality Care and Documentation for Sustainable Revenue
In our latest Masterminds discussion, Beyond Heads & Beds: Quality Care and Documentation for Sustainable Revenue, Sarah Wirt and Melissa Sanders, Clinical Documentation Specialists at Hansei Solutions, provided valuable insights into the critical role of medical documentation in improving patient care, reducing denials, and ensuring sustainable revenue.
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Key Takeaways
The discussion underscored the importance of quality over quantity in documentation. Clear, consistent, and individualized records are essential for effective payor communication and compliance with industry standards. Common documentation errors—such as mismatched diagnosis codes, missing signatures, and vague clinical notes—can lead to increased denials and revenue loss.
Best Practices for Stronger Documentation
🔹 Understand Payor-Specific Requirements – Each payor has unique documentation expectations. Building collaborative relationships with payors can lead to better outcomes and fewer denials.
🔹 Internal Audits Are Key – Regularly reviewing documentation ensures accuracy and compliance. Sarah and Melissa recommended weekly audits for inpatient facilities and bi-weekly audits for outpatient settings to proactively catch errors.
🔹 Institutional Knowledge Matters – Encouraging staff to track what works (and what doesn’t) when engaging with insurance reviewers can help facilities refine their approach and improve approval rates.
🔹 Training & Consistency – Staff should be trained to properly match diagnosis codes with the level of care provided and maintain consistency across the medical record.
🔹 Leveraging 3.1 Level of Care in California – We also explored strategies for getting this level of care approved by insurers, helping providers expand access to needed services.
Actionable Steps for Providers
✅ Develop a shared document of common terminology and best practices for documentation.
✅ Encourage staff to document interactions with insurance reviewers to build internal knowledge.
✅ Implement structured internal audits to ensure accuracy and completeness.
✅ Offer ongoing training on documentation best practices, diagnosis codes, and payor-specific requirements.
Providers can enhance patient care while protecting revenue by focusing on proactive documentation strategies and payor collaboration. This conversation highlighted the need for ongoing education, internal processes, and a commitment to excellence in medical documentation.
Sarah Wirtz
Clinical Documentation Specialist, LCDC
Hansei Solutions
Melissa Sanders
Clinical Documentation Specialist, LMFT, MBA
Hansei Solutions
