The Misunderstanding Over Secondary Review

By Mary McGrady Published in ICD10monitor July 13, 2026

Inpatient documentation has grown increasingly complex. Clinical nuances are distributed across lengthy progress notes, consultations, diagnostic findings, and evolving treatment plans. At the same time, health information management (HIM) and clinical documentation integrity (CDI) professionals are under more pressure to support quality reporting and benchmarking by ensuring that the final coded record accurately reflects the care delivered.

Secondary review is sometimes seen as a corrective backup. The thinking is that if documentation and coding were “done right the first time,” secondary review would not be necessary. In practice, however, structured secondary review is not a redundancy. In mature governance models, it serves as a layer of quality assurance that protects the accuracy and defensibility of the final coded record.

Secondary Review as an Integrity Safeguard

Even well-run CDI programs inevitably find interpretive variability. Complex inpatient cases often contain cumulative clinical signals that are subtle or evolving. They may be documented across multiple encounters and providers. In fact, two qualified professionals reviewing the same chart may differ in how they assess severity. They may also interpret clinical relationships differently.

A structured secondary review brings consistency to that complexity. It creates a formal opportunity to reassess whether the coded outcome fully represents the clinical picture documented in the record. When thoughtfully implemented, this process strengthens alignment between clinical documentation, coding decisions, and reporting outcomes.

The impact reaches well beyond reimbursement. When severity is understated, the case is represented differently in the data. Case mix index (CMI) may not fully reflect the complexity of the patient population. Severity of illness (SOI) and risk of mortality (ROM) scores can also be lower than the clinical picture supports. Those differences can influence mortality comparisons and internal performance reporting. They can also shape how service lines are viewed and evaluated.

In some situations, incomplete representation can leave an organization exposed to downgrades or denials. That exposure is not always tied to the care delivered. Often, it comes down to whether the documentation clearly supports the coded result. A structured secondary review provides an opportunity to catch those gaps before the record becomes part of the organization’s permanent reporting history.

This additional review layer should not be interpreted as a lack of confidence in CDI or coding teams. Most variability stems from the complexity of the record itself. Secondary review simply adds another checkpoint. In high-volume environments, where documentation standards and regulatory expectations continue to evolve, that checkpoint can protect both accuracy and consistency.

Using AI to Target Expertise

As documentation volumes continue to grow, reviewing every inpatient case at multiple levels becomes difficult to sustain. Many healthcare organizations are already incorporating artificial intelligence (AI) into administrative and recordkeeping tasks. A 2024 HIMSS/Medscape survey found that AI is most often used for transcription and patient-related recordkeeping, including clinical documentation and coding functions.

AI systems can process large amounts of structured and unstructured data quickly. They can surface documentation patterns and highlight cases that deserve a closer look. In a secondary review model, this can help teams focus their time on records for which the impact of interpretation is likely to be meaningful.

That distinction matters. AI can identify signals, but it does not determine how those signals ultimately should be represented in the coded record. Decisions about sequencing and clinical relationships still require trained clinical–coding expertise. Those determinations carry compliance implications and affect long-term reporting.

As AI becomes more integrated into documentation and coding workflows, the role of HIM and CDI professionals continues to center on oversight and accountability. Technology may help with case identification, but the responsibility for interpretive judgment remains human-centered.

Governance and Role Clarity in AI-Supported Review

Secondary review works best when it operates within a clearly defined governance structure. Without role clarity, processes can become inconsistent. They can also create friction between teams.

Organizations that incorporate secondary review into their documentation integrity strategy benefit from defined responsibilities. Who performs the review? At what stage does it occur? How are findings documented? How are updates applied? These questions should be addressed before the process is put into place.

Interpretive authority is especially important. When more than one professional reviews a record, there must be a clear framework for how final determinations are made. This is not about hierarchy, but consistency and defensibility. Defined decision pathways help reduce variability and support compliance.

Transparency also matters. Secondary review activity should be visible within the organization’s systems. Reporting should emphasize recurring patterns, rather than one-off cases. Aggregate findings can guide documentation education and policy refinement without disrupting daily workflows.

Plus, structured oversight helps protect the integrity of the process itself. Federal Medicaid guidance makes clear that providers must maintain records that fully disclose the extent of services furnished and support claims submitted for payment. Secondary review operates within that expectation. Quality checks and documented rationale reinforce accountability and help ensure that the coded record reflects what is supported in the medical record. These safeguards keep secondary review aligned with accurate clinical representation, rather than reactive correction.

When governance and defined responsibilities are in place, secondary review supports confidence in the final coded record and reinforces the standards that HIM and CDI professionals are responsible for upholding.

From Retrospective Insight to Sustainable Improvement

Secondary review generates insight into documentation patterns and areas where interpretation frequently varies. At an aggregate level, those patterns can inform broader improvement efforts.

Retrospective findings are most useful when they aren’t confined to the review team. As cases accumulate, specific themes start to surface. Some diagnoses are repeatedly clarified. Certain documentation elements tend to create confusion. Those patterns are where the real opportunity sits.

When teams step back and look at trends instead of individual cases, education becomes more focused. Query language can be adjusted, and internal guidance can be clarified. The goal is not to revisit isolated charts, but to understand what keeps recurring, and why.

This continuous feedback loop strengthens the overall integrity framework. As documentation becomes clearer, coding decisions become more consistent. Fewer cases require correction after the fact.

None of this happens from a single intervention. It develops gradually. Each review cycle adds a little more clarity, and expectations become easier to articulate. Over time, secondary review stops feeling like an end-stage safeguard and starts functioning as part of the organization’s normal quality discipline.