Chart Review & Documentation Defense
Master techniques for defending clinical documentation and coding decisions
- Analyze chart documentation to identify defensible vs. indefensible coding
- Build compelling clinical arguments using available documentation
- Distinguish between documentation gaps and clinical inappropriateness
- Present medical necessity arguments effectively
- Balance acceptance of errors with defense of appropriate coding
The 4-Question Defense Analysis
1. Was the diagnosis clinically present?
Look for: Clinical indicators, symptoms, diagnostic test results, physical findings
2. Did it impact patient care?
Look for: Treatment provided, therapy modifications, nursing interventions, monitoring required
3. Is there physician documentation?
Look for: H&P, progress notes, orders, problem list - any physician documentation counts
4. Does it meet coding criteria?
Look for: Specific clinical criteria for tier assignment, ICD-10 requirements
If all 4 = YES: Strong defense. If 3 = YES: Moderate defense. If 2 or less = Accept finding.
Common MAC Challenges & Defense Strategies
Challenge: "Physician didn't specify diagnosis details"
Defense: Present supporting clinical documentation (labs, imaging, clinical indicators) that demonstrates the specific diagnosis was clinically present and appropriately treated, even if physician's documentation lacked specificity. Acknowledge documentation could be improved.
Challenge: "FIM scores don't match functional documentation"
Defense: Explain FIM scoring methodology - scores reflect typical performance with safety considerations, not best performance. Present documentation of safety concerns, consistency issues, or factors affecting functional status that justify the score.
Challenge: "Comorbidity wasn't actively treated"
Defense: Show how comorbidity impacted care: Monitoring required, therapy modifications, precautions implemented, nursing interventions, medication management. Impact on care is broader than just "treatment."
Challenge: "Medical necessity not supported"
Defense: Present physician documentation of: Complex medical needs, 3-hour therapy tolerance, need for physician oversight, clinical factors making lower level of care inadequate. Focus on clinical complexity, not just therapy minutes.
Building a Strong Defense Package
Essential Components:
- • Cover letter: Professional summary of your position
- • Case-by-case analysis: Detailed response to each finding
- • Clinical documentation: Highlighted relevant sections
- • Coding references: Guidelines, Coding Clinic, CMS guidance
- • Clinical rationale: Explain why coding was appropriate
- • Corrective actions: Show you've addressed any issues
- • Compliance evidence: Audit results, training records, policies
When to Accept vs. Defend
ACCEPT the finding when:
- • No physician documentation exists
- • Clinical criteria clearly not met
- • Documentation states "rule out" or "possible"
- • Comorbidity had no impact on care
- • Clear coding error
DEFEND the finding when:
- • Physician documentation exists (any form)
- • Clinical indicators support diagnosis
- • Comorbidity impacted care plan
- • Coding follows published guidelines
- • Clinical appropriateness is clear
Professional Defense Communication
DO:
- • Use professional, respectful tone
- • Focus on clinical care and patient needs
- • Acknowledge documentation gaps while defending clinical appropriateness
- • Provide specific references and evidence
- • Show commitment to compliance and improvement
DON'T:
- • Use defensive or adversarial tone
- • Mention reimbursement or financial impact
- • Blame physicians or staff
- • Make excuses for poor documentation
- • Argue without supporting evidence
10
Questions
90%
Passing Score
~15
Minutes
Quiz Instructions:
- Answer all 10 questions to complete the quiz
- You must score 90% or higher to pass
- You can navigate between questions before submitting
- Review explanations for all questions after submission
- Retake the quiz as many times as needed to pass