Defensible Documentation: Preparing for Audit, Review, and Risk Adjustment Scrutiny

Clinical documentation serves as more than a record of care—it is the primary source of evidence used to support coding, medical necessity, quality reporting, and risk adjustment. As audit activity continues to increase across healthcare, organizations are facing growing scrutiny regarding whether documentation fully supports the diagnoses, services, and level of care reported.

This session will examine documentation through the lens of evidence, focusing on how regulatory agencies and payers evaluate the medical record during audits and reviews. Participants will gain insight into the difference between documentation completeness and clinical validity, and why both are essential in supporting defensible coding and billing practices.

The session will also explore common documentation vulnerabilities that lead to denials, audit findings, and compliance risk. Attendees will learn how documentation is interpreted in the context of risk adjustment and audit methodologies, and how gaps in provider documentation can impact both reimbursement and organizational performance.

Practical strategies will be shared to strengthen documentation practices, improve alignment between clinical care and the medical record, and enhance the ability to support reported diagnoses and services. This session is designed to help healthcare professionals better understand how documentation is used as evidence and how to improve documentation integrity in an increasingly scrutinized environment.

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• The role of documentation as evidence in healthcare
• How audits and reviews evaluate the medical record
• Documentation completeness vs clinical validity
• Common audit findings related to documentation gaps
• Risk adjustment and documentation requirements
• The impact of documentation on compliance and reimbursement
• Provider documentation challenges and opportunities
• Strategies to improve documentation defensibility
• Aligning documentation with coding and regulatory expectations
• Practical examples of documentation improvement
• Live Q&A Session

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Penny Jefferson, MSN, RN, CCDS, CCDS-O, CDIP, CCS, CRC, CHDA, CRCR, CPHQ, ACPA-C, is the Director of Clinical Documentation Integrity at UC Davis Health, where she leads enterprise-wide initiatives focused on improving documentation accuracy, medical necessity support, and revenue integrity. She brings extensive experience in CDI, revenue cycle operations, and regulatory compliance, with a focus on aligning documentation practices to meet evolving payer and regulatory expectations.
Penny is a national speaker and educator, serving as a co-host of Talk Ten Tuesday and a recognized thought leader in the CDI and physician advisor space. She is actively involved in the American College of Physician Advisors (ACPA), where she co-chairs the CDI Committee and leads the CommUnity Denials and Appeals focus group, bringing together interdisciplinary leaders to address emerging challenges in documentation and audit defense.
She is known for translating complex regulatory and operational concepts into practical, actionable strategies that help healthcare teams improve documentation integrity, reduce denials, and strengthen overall revenue performance.

Additional Information

Snippets From Our Previous Session