Precision of Language Matters: Taking Credit for Complexity of Care

Session Description: In a time where healthcare reimbursement and public reporting hinge on accurate data, the precision of language and documentation has never been more critical. This session will explore a real-world case study from a health system that conducted a retrospective review of over 3,500 surgical procedures to evaluate gaps in electronic medical record abstracted data. The analysis revealed that more than 20% of procedures required updates to capture key elements of patient complexity—resulting in an increase of two additional expected surgical site infections in a 12-month submission period. These findings underscore how incomplete or imprecise abstraction can negatively impact risk adjustment, skew surgical site infections rates, and reduce Medicare pay-for-performance reimbursement.

A multidisciplinary team—including infection prevention, informatics, electronic medical record analysts, anesthesia, surgeons, and coding professionals—collaborated to identify documentation gaps, improve abstraction accuracy, and strengthen data validation processes. Through this collaborative approach, the organization implemented meaningful changes to ensure accurate reporting and recognition of the complex care provided to surgical patients.

Attendees will gain practical insights into documentation strategies, abstraction workflows, and communication tools used to close these gaps. This session equips infection preventionists with knowledge and tactics to validate electronic medical record derived data, advocate for abstraction accuracy, and ensure their institutions receive appropriate credit for caring for complex surgical patients.

Rebecca Lewis

System Director, Infection Prevention, INTEGRIS Health

Becky Lewis is the System Director of Infection Prevention for INTEGRIS Health, the largest healthcare system in Oklahoma. With 20 years of nursing and 17 years of infection prevention, Becky has built a career at the intersection of data, science and people. Having navigated two global pandemics, she remains deeply humbled by the resilience of the profession and the ability to challenge the status quo, adapt, and grow through adversity. Among her proudest professional achievements was the expansion of her IP program from 6.5 FTEs in 2015 for 1,200 inpatient beds to more than 17 FTEs in 2024 for over 1,800 beds. Together, this team has built a robust, trusted program focused on creating safer healthcare environments for patients, employees and the community. Because everyone is someone’s most important person and deserves the safest care possible.