What is clinical documentation for billing?
It is the record, made by the care team, that lets the hospital claim prove three things: what was done, why it was needed and who did it. Without that record, an item can be denied even if it was delivered.
The acronym CDI comes from the U.S., where it started as clinical documentation improvement. In 2019, the Association of Clinical Documentation Integrity Specialists (ACDIS) replaced “improvement” with “integrity” and warned that treating CDI only as a revenue tool had led to inappropriate practices [10]. The point holds in Brazil: the goal is a complete and accurate record, not a larger claim.
The payment model is different. In the U.S., CDI relies on diagnosis coding that drives DRG payment. In Brazil, 58.6% of health plans' medical expenses were paid fee-for-service in 2025, versus 13.1% through bundles [9]. In that model, each line on the claim needs support in the medical record. The pillar guide on medical claims auditing shows how that support is checked on both sides.
In this guide, operadora means the health plan (private health insurer regulated in Brazil). The ANS (Agência Nacional de Saúde Suplementar, Brazil's National Supplementary Health Agency) regulates health plans and maintains TISS (the mandatory electronic data exchange standard between hospitals and health plans) and TUSS (its unified terminology of codes).
The medical record is an ethical duty before it is a billing document
The duty to document comes from CFM rules, not from the contract with the health plan. CFM Resolution 1,638/2002 (Resolução CFM nº 1.638/2002, on the medical record) defines the record as a single document of a legal, confidential and scientific nature (art. 1) [1]. Responsibility lies with the attending physician, the other professionals involved, department heads and the medical director (art. 2) [1].
The Code of Medical Ethics (Código de Ética Médica, CFM Resolution 2,217/2018) reinforces the rule [2]:
- Art. 87: physicians may not fail to keep a legible record for each patient; § 1 requires clinical data in chronological order, with date, time, signature and CRM number.
- Art. 80: physicians may not issue a medical document without a professional act to justify it, or one that does not reflect the truth.
- Art. 11: physicians may not issue an illegible report or certificate, or one without the CRM number.
Article 80 sets the limit for any documentation program. Better documentation means describing precisely what happened; documenting to bill for what did not happen is an ethics violation.
Digital records are governed by Law 13,787/2018 (Lei nº 13.787/2018, on digitization of medical records) and CFM Resolution 1,821/2007. For digitization, the law requires a digital certificate issued under the Brazilian public key infrastructure (ICP-Brasil) or another legally accepted standard (art. 2, § 2), gives digitized records the same evidentiary value as the original (art. 5) and sets a minimum retention of 20 years from the last entry (art. 6) [3][4]. Since 08/26/2026, CFM Resolution 2,454/2026 also requires recording the use of artificial intelligence in care in the medical record (art. 4, V) [11].
What do physicians need to record?
Article 5 of CFM Resolution 1,638/2002 lists the items the hospital's Medical Record Review Committee must check [1]. The table links each item to what it supports on the claim and to what is often missing.
| Record | What the rule requires | What it supports on the claim | Common gap |
|---|---|---|---|
| Patient identification | Full name, date of birth with four-digit year, sex, mother's name, place of birth, address (art. 5, I, a) [1] | Eligibility and match with the TISS form | Data that differ from the member card |
| History, physical exam and hypotheses | History, exam, tests ordered and results, diagnostic hypotheses, final diagnosis and treatment (art. 5, I, b) [1] | Medical necessity for admission and procedure; ICD code on the form | Complaint without severity; nonspecific ICD |
| Daily progress notes | Date and time, every procedure and who performed it (art. 5, I, c) [1] | Room and board, length of stay, ICU, tests and therapies of the day | Note copied from the previous day; day with no note |
| Orders | Date, time, signature and CRM (art. 87, § 1) [2] | Drugs, supplies and diets billed | Item given without an order; expired order |
| Operative and anesthesia reports | Account of procedures and who performed them (art. 5, I, c) [1] | Procedure code, surgical approach, team and fees, implants | Procedure described differs from the authorized one; incomplete team |
| Implant justification | Clinical justification and labels in the record (CFM Resolution 2,318/2022, arts. 3 and 7) [8] | Payment for the implant | Missing label; generic justification |
| Professional identification | Legible handwriting, signature and CRM on paper; electronic signature in the system (art. 5, I, c and d) [1] | Validity of every entry | Stamp without signature; shared login |
| Discharge summary | Prepared and delivered by the attending physician (art. 87, § 3) [2] | Closing the claim, principal and secondary ICD codes | Generic or missing summary |
Nursing completes the picture. Medication administration, vital signs and wound care are in the nursing record, governed by Federal Nursing Council (Cofen) Resolutions 736/2024 (nursing process) and 754/2024 (electronic nursing record) [7]. The guide on nursing audit covers that side.
Which denials come from poor documentation?
Table 38 of TUSS lists the messages health plans use to justify a denial. A search of the ANS database on 10/17/2026 shows several tied to documentation [5]:
| Group | Codes and descriptions (TUSS 38) | Record that prevents it |
|---|---|---|
| Progress notes | 2511 no progress note in the medical record for serial treatment (effective 12/01/2025); 2512 physical therapy sessions inconsistent with progress notes | Complete daily progress notes |
| Signature | 3170 missing signature/stamp of the ordering professional (12/01/2025); 3168 invalid or missing digital signature (10/01/2022) | Professional identification |
| Report | 3155 partograph or medical report not available to the health plan (05/01/2016); 1822 procedure billed without the test result or technical report (12/01/2025) | Reports and operative notes |
| Consistency with the report | 3212 procedure or item inconsistent with the technical report (12/01/2025) | Orders and operative notes aligned with the claim |
| Justification | 3217 missing or insufficient justification (12/01/2025) | Explicit medical necessity |
| Length of stay | 1903 stay inconsistent with clinical progress | Progress notes that describe severity |
| ICD | 1509 invalid ICD code | Consistent diagnosis and ICD code |
The TISS form reports the diagnosis using the ICD (International Classification of Diseases; CID in Portuguese). The standard's Organizational Component bars health plans from requiring the ICD code on claim forms, as a result of a court decision (item 28) [12]. The guide on TISS denial codes explains how to read these messages in the payment report.
How does a clinical documentation program work in the hospital?
It works as a review of the medical record during the stay, with queries to the physician before discharge. The flow below is a practical adaptation; no Brazilian rule defines a CDI program.
- Documentation. Physicians and nurses record care in the medical record.
- Concurrent review. A reviewer (a nurse or physician from internal audit) reads the record during the stay, focusing on progress notes, orders, justifications and ICD codes. The guide on prospective, concurrent and retrospective audit explains this approach.
- Physician query. When information is missing, the reviewer asks in writing, with an open question (“what was the indication for changing the antibiotic?”), without suggesting a diagnosis or treatment.
- Amendment by the author. Only the physician adds to his or her own note, with a new date and time, without deleting the original.
- Claim and feedback. Billing builds the claim from the record; internal audit checks it before submission; denials feed back into physician education.
Step 4 is the sensitive one. The Medical Record Review Committee, mandatory and led by a physician (arts. 3 and 4 of Resolution 1,638/2002), is the natural forum to approve the program's rules [1]. When the health plan audits, CFM Resolution 2,448/2025 provides for on-site access to the record, without removing or copying it (art. 10, II) [6]; the guide on physician audit covers which articles are suspended by court order.
Engaging physicians starts with showing them their own problem
Physicians document better when they see what gaps cost the patient, themselves and the hospital. Practices that tend to work:
- Speak the clinical language. Show that incomplete notes harm continuity of care and the physician's defense, not just revenue.
- Give individual feedback. A monthly report by physician or team with documentation-related denials, in value and number of claims.
- Reduce workload. Templates for progress and operative notes with required fields in the system, without prefilled text that invites copy-paste.
- Link fees and documentation. The operative note defines team, approach and level of participation; the guide on physician fees on the hospital claim shows the effect on the physician's own payment.
- Involve the medical director. Responsibility for the record extends to that role (arts. 2 and 5, II, of Resolution 1,638/2002) [1].
What we see in operations
At Accrua, clinical documentation is read while the patient is still in the hospital, because that is when the physician can still complete the record. Accrua OS reads progress notes, prescriptions, operative reports and other reports and checks whether they support what goes on the claim: a procedure consistent with the ICD code, the requesting physician's signature, justification for the length of stay, the OPME label.
When a record is missing, the query reaches the physician with the claim item and the health plan's rule alongside it, not as a generic request for review. That shows the problem that matters to them: a procedure they performed that may not be paid. The clinical decision and the record remain the physician's.
In our managed operation, auditors with nursing backgrounds track open queries by unit and by claim type. Every query and every change is logged in an audit trail, and what we learn from one appeal goes back into the next claim.
Where to start
- Map documentation-related denials over the last 6 months, grouped by the TUSS table 38 messages above.
- Activate the Medical Record Review Committee as the program's forum, with a monthly agenda on documentation denials.
- Define required fields for progress notes, orders and operative notes in the electronic record.
- Start concurrent review with surgical and ICU stays, where implants, room and board and fees concentrate.
- Publish monthly feedback by medical team, with real anonymized cases.