How Documentation Accuracy Affects Outcomes

U.S. News and World Report just released its 2025-26 ranking of the nation’s best hospitals. As always I’m interested in what you think of these rankings, and secondarily how much your hospital and its CDI and coding programs use the list as a barometer of success. (FYI NYU Langone is crushing it). I thought this was an interesting bit, don't abandon your local community hospital to get a colonoscopy at Mayo: “For most illnesses, patients do not need to go to an Honor Roll hospital, which may require traveling away from home and paying expenses for out-of-network care. All rankings and ratings should be seen as just a starting point for patients considering where to seek care with input from their doctors. Individual diagnosis, insurance coverage and priorities are important factors in making a personal best choice.” But what I really want to focus on is how the work of a CDI or coding professional can impact your ranking, particularly through observed-to-expected (O/E) ratios for complications. U.S. News uses risk-adjusted outcome measures in its rankings including specialties like cardiology, GI surgery, and orthopedics. One key metric is the O/E ratio for complications, which compares the actual rate of complications observed at a hospital (numerator) to the rate statistically expected based on patient complexity and risk (denominator). As I’ve noted before a great takeaway is to educate your coders and CDI professionals on the Elixhauser methodology, as U.S. News and World Report uses it. This is confirmed again in the published U.S. News and World Report methodology (see links below). Correctly capturing patient complexity through coding and documentation directly affects the expected portion of this ratio. If documentation is incomplete or vague, the patient may appear less sick than they truly are — reducing the expected rate of complications and making the hospital look worse when complications occur. Example: Acute Kidney Injury (AKI) and a CDI query Clinical scenario: A 76-year-old male undergoes major abdominal surgery. Post-op, he experiences a transient rise in creatinine. The physician documents “mild renal dysfunction.” A CDI specialist notices that the labs meet KDIGO criteria for AKI (e.g., creatinine increase >0.3 mg/dL within 48 hours) and issues a clarification. Provider response: “Yes, this represents Stage 1 AKI due to hypotension.” Without this CDI clarification, expected complications are lower, because the patient seems healthier. But the observed complications are higher (AKI is captured anyway via lab data or NSQIP abstraction). And your O/E ratio is worse … it appears your hospital underperformed. With the clarification expected complications are appropriately higher, due to documented AKI and comorbid hypotension. Observed complications are the same, and the O/E ratio is closer to 1 (or possibly <1). This reflects well-managed complex care … and helps with your U.S. News and World Report rankings.

In today's world, where it’s hard to distinguish between AI-generated content and real facts, solid documentation is more important than ever. In the power industry, context is everything, and effective communication between engineering teams, site personnel, and management is essential to maintaining accurate records. As new technologies are introduced, how are you tracking changes, modifications and upgrades to your facilities? From protection systems and inverter settings to data center additions, we've seen it all. Being able to document these changes along with the reasoning behind decisions is critical. Its more than just ticking a box - its about keeping record of **why** certain actions were taken. I am especially proud of my team for focusing on the 'what happens next' aspect of compliance. Some examples of this - when electrotechnical relays are switched to solid state ones at a hydroelectric unit, what engineering studies need to be updated? Another example, when adding BESS(Grid scale storage) - how do we ensure all needed checks are done? Clear documentation makes the compliance process so much easier and ensure that no small change is overlooked. Its like what I tell my kids - cleaning up small messes now prevent bigger problems later. Good documentation doesn't just assist the compliance process - it allows us to track trends and spot larger portfolio performance issues and saves the rationale behind decisions for the next person stepping into a role. At the end of the day, its these small things, checklists, qualifying questions and RFI's that contribute to a stable, reliable grid. #NERC #Engineering #InternalControls #Compliance

Anyone can put words on a page. That doesn’t make it good documentation. A document isn’t "done" once it’s written. If it hasn’t been researched, structured, and validated, it’s just text— not a reliable resource. Unvalidated documentation: 🔴 Feels complete but is full of assumptions 🔴 Misses key details or uses incorrect terminology 🔴 Leads to confusion, errors, and rework Well-researched, structured, and validated documentation: 🟢 Is based on real user needs and technical accuracy 🟢 Follows a logical structure for usability 🟢 Has been reviewed, tested, and refined for clarity Technical writing isn’t about writing—it’s about building resources that actually work. Is your documentation just written, or is it proven to be right? #TechnicalWriting #Documentation #ProcessMatters #Accuracy

The Impact of Accurate Documentation: Real-World Examples from an OIG Audit The importance of accurate condition capture and documentation in risk adjustment cannot be overstated. A recent OIG random review of EmblemHealth highlights just how much is at stake when conditions are incorrectly reported—or overlooked entirely. Here are three patient scenarios uncovered in the audit: Enrollee A • Submitted HCCs: 3 • Validated HCCs: 2 • Review Findings: The submitted HCC for Polyneuropathy was not supported by the medical record. • Impact: $1,992 overpayment to the plan. Enrollee B • Submitted HCCs: 2 • Validated HCCs: 2 • Review Findings: While the submitted HCC for Diabetes Mellitus (DM) with complications was not supported, the documentation did validate DM without complications. • Impact: $2,328 overpayment to the plan. Enrollee C • Submitted HCCs: 2 • Validated HCCs: 4 • Review Findings: Reviewers not only validated the submitted HCCs but also identified two additional HCCs that had not been submitted in claims. • Impact: $4,438 underpayment to the plan. The Takeaways The OIG review illustrates several key themes: 1. Documentation Gaps: Unsupported conditions can lead to overpayments, exposing plans to potential financial penalties and compliance risks. 2. Missed Opportunities: Inaccurate or incomplete submissions may result in underpayments, reducing the resources available to care for complex patients. 3. Importance of Proactive Reviews: Comprehensive reviews of documentation and coding practices can identify discrepancies before they escalate into larger issues. A Path Forward: Best Practices To mitigate risks and ensure accuracy: • Train Providers Continuously: Reinforce the importance of detailed documentation that supports all submitted diagnoses. • Conduct Pre-Bill Reviews: High-risk HCCs should undergo additional scrutiny before claims submission. • Leverage Retrospective Audits: These reviews can identify and address both unsupported claims and missed conditions, ensuring accurate risk scoring. The financial and compliance stakes are high. The EmblemHealth review revealed a $552,000 overpayment recommendation from the OIG, with 25% of submitted conditions unsupported by medical records. On the flip side, 65 additional conditions were identified but not submitted, representing missed opportunities for accurate risk adjustment. In risk adjustment, accuracy is everything. How does your organization close the gap between documentation and coding? Let’s connect and share strategies.