In these situations, it is a more prudent move to query the physician concurrently, according to Elizabeth Lamkin, MHA,partner, PACE Healthcare Consulting, LLC.
"Accurate documentation begins with the proper review by case management and physician advisor to give guidance to the attending/admitting physician," she said. "I'd recommend a clinical documentation improvement specialist (CDIS) to then review the documentation concurrently and assist the physician in navigating the chart."
If the physician documentation missed a note from a consulting physician or someone in the therapy department, for example, the CDIS can notify and query the physician during the patient's stay for clarification, she said. "The result should be more accurate documentation, better coding in the health information management (HIM) department, and appropriate reimbursement and billing compliance."