Document Like a Pro: Capture Acuity, Maximize Coding, Protect Revenue

Course Description

Accurate, detailed, and clinically aligned documentation is the foundation of compliant coding, accurate reimbursement, and reliable patient risk stratification. As healthcare continues to shift toward value-based models and “upstream drivers” gain renewed attention, capturing true patient acuity has never been more important. In this one-hour webinar, participants will learn practical, real-world strategies to enhance documentation integrity—ensuring that diagnoses reflect severity, complexity, and the patient’s full clinical picture.

This session breaks down what auditors look for, how ICD-10 specificity impacts coding accuracy, and why chronic conditions, complications, and functional limitations must be documented every time they are assessed or influence care. We will explore common gaps that lead to lost revenue and inaccurate data—including missed 4th–7th characters, lack of linkage between conditions, underreported chronic diseases, and improper use of unspecified codes.

Participants will also learn how to leverage combination codes, functional status coding, and “upstream driver” reporting to strengthen acuity capture. Clear examples, best-practice tips, and actionable documentation phrases will help clinicians and coding teams work together to paint a more complete picture of each patient. If you teach, lead, code, audit, or support clinical documentation, this session will give you the tools to immediately improve accuracy and compliance.

Learning Outcomes:

• Identify documentation elements required to code to the highest level of specificity
• Recognize how acuity, severity, and clinical descriptors influence code selection
• Link diagnoses with related conditions and manifestations to reflect true complexity
• Apply MEAT criteria consistently when capturing chronic conditions
• Understand when and how to report combination codes for clearer clinical storytelling
• Incorporate functional status, dependence, and “upstream drivers” into documentation
• Document complications accurately, including the underlying cause when appropriate
• Align documentation with medical decision-making to support acuity and audit readiness

Areas Covered in the Session:

• Coding to the highest level of ICD-10 specificity (4th–7th characters)
• Documenting severity: acute, chronic, exacerbations, stages, and grades
• Linking diagnoses to manifestations (e.g., diabetes with neuropathy)
• Capturing all active chronic conditions using the MEAT framework
• When and how to use combination codes to reflect complexity
• Reporting “upstream drivers” such as housing instability and food insecurity
• Documenting functional status, dependence, and risk factors
• Accurately reporting complications and adverse events
• Appropriate application of the 7th character for injuries and sequelae
• Ensuring MDM and documentation support true acuity for audit validation
• Live Q&A Session

Recommended participants:

• Physicians and Advanced Practice Providers
• Medical Coders and Billers
• Clinical Documentation Improvement (CDI) Specialists
• Practice Managers and Administrators
• Quality and Compliance Professionals
• Revenue Cycle Leaders
• Risk Adjustment and Population Health Staff
• Nurses and Clinical Support Staff Involved in Documentation

About the Presenter

Jan Hailey, MHL, CMOM, CMIS, CMCO, CMC, CMCA-E/M is the CEO and Founder of Practice Matters, LLC, a healthcare consulting and education firm specializing in revenue cycle optimization, compliance, medical practice operations, and workforce development. With more than 30 years of experience in healthcare administration, coding, billing, and clinical documentation improvement, Jan is known for transforming complex regulatory and operational concepts into practical, actionable strategies for medical practices nationwide.

As CEO of Practice Matters, Jan partners with medical groups, health systems, and professional organizations to strengthen operational efficiency, improve financial performance, and elevate staff competency through customized training and consulting services.

Jan’s career includes extensive leadership experience across quality, coding, compliance, and care management. She has served as Director of Coding, Quality, and Compliance, Director of Quality, and Director of Care Management within large multispecialty practice and network environments. In these roles, she led interdisciplinary teams across clinical and administrative departments, driving improvements in care coordination, documentation accuracy, operational efficiency, and patient experience. She also developed comprehensive HCC education programs and documentation improvement strategies that helped providers accurately capture patient complexity and strengthen population health performance.

Jan holds a Master of Health Leadership and multiple industry certifications in office management, insurance processing, coding, and compliance. She also serves on the WPS Government Health Administrators (Medicare) Provider Outreach and Advisory Group, contributing her expertise to help enhance provider education and communication at the Medicare contractor level.