Revenue and Quality Integrity: A Comprehensive Approach to Coding, Compliance, and Clinical Documentation


In this era of declining reimbursements and the growing prevalence of value-based payments, accurate reporting of clinical services, quality metrics, and risk adjustment factors is imperative for any healthcare provider. This paper presents an approach to coding, compliance, and clinical documentation to support the revenue and quality integrity (RQI) of the provider.

Too Much To Do in Too Little Time

The fact is providers now face the challenge of doing much more in less time than in the past regarding clinical documentation and coding. Consider the following actions that must occur within the now standard 15-minute patient office visit.

  1. Code accurately the E&M level for the visit
  2. Document correctly to justify the E&M level
  3. Assign the ICD-diagnostic codes
  4. Identify and address the hierarchical condition codes (HCCs) mentioned in the office note so that they can be used to risk adjust quality and cost performance data related to the visit.

The RQI Approach

There is no doubt that the four steps, above, cannot be done without a systematic and technology supported process that relieves the burden placed on providers related to coding and clinical documentation compliance. The provider’s first and foremost responsibility in this theoretical 15-minute visit is to care for the clinical needs of the patient in a reliably high-quality fashion during this short period. Without a standardized process and utilization of tools and technologies that support the documentation and coding components of the visit, the provider will naturally (and appropriately) focus more on the clinical care tasks at hand. Comprehensive support at this level requires experts in all aspects of coding to include E&M, CPT, ICD-10, and risk adjustment (HCC capture). Organizations should be conducting coding reviews, audits, and education in these areas for staff and providers regularly. This routine is especially important for providers who now must perform most of the coding tasks in the ambulatory arena themselves.

In the outpatient areas, then, professional coders need to play more of a support role and ensure through education and training that their providers have the knowledge and expertise necessary to see that tasks, such as E&M coding and associated clinical documentation, are done compliantly. An organization that takes the RQI approach must understand that accurate and complete coding begins with appropriate documentation of clinical services. Hospitals and other healthcare providers must build clinical documentation improvement (CDI) programs to improve current CDI activities both in the inpatient or ambulatory setting.

Clinical Documentation Improvement (CDI)

The ideal CDI program will include certified coders (CPC), health information professionals (RHIA), and clinically-trained professionals (RNs and MDs) who have worked in this field for years. Realistically, however, many organizations, notably smaller or rural facilities, do not have the depth nor breadth of personnel necessary to staff a CDI program in this manner. Thus, it is crucial to outsource some or all of these needs to qualified experts.

IT Support

Healthcare organizations of all types and sizes also need to look to IT vendors who can provide them with the tools and technology necessary to streamline and support coding and clinical documentation activities. Technology is now available that can help automate accurate coding assignments (ICD-10, DRG, CPT to include EM) and HCC identification and capture. The best of these systems use capabilities, such as natural language processing (NLP) and artificial intelligence (AI), to read or listen to a provider’s notations and help guide them through the coding and clinical documentation process.

Managing Risk

Finally, much depends on getting this part of an organization’s operations right. First, there are compliance risks involved that have increased in complexity as more and more payments are now “value-based,” i.e., reimbursements are no longer merely dependent on submitting accurate invoices for services but also now depend on accurately reporting quality and cost performance data along with accurate risk-adjustment factors. Penalties for not complying with these requirements are not insignificant and warrant carefully constructed compliance plans in these areas. Second, in a value-based reimbursement environment, the financial success of an organization most definitely depends on a well-constructed coding and documentation system using the RQI approach. Those systems that have worked well in a predominantly fee-for-service economy will no longer suffice in reimbursement models that are moving quickly toward a more fee-for-value methodology.


In brief, the integrity of your revenue and quality data reporting is essential to your organization’s success and should be reviewed, revised, and improved as the healthcare industry continues to evolve. The RQI approach is a comprehensive approach to achieving that goal.

Related Insights