Documentation as Defense: Navigating Denials in a Less Aligned System

EDITOR’S NOTE:

Ongoing discussion about U.S. disengagement from the World Health Organization (WHO), with withdrawal effective Jan. 22, has refocused attention on how global standards influence downstream interpretation. For hospitals, the operational issue is not regulatory change, but how documentation is evaluated when shared clinical reference points become less consistent.

In January 2025, the White House issued a formal statement announcing the Administration’s intent to withdraw from the WHO, citing concerns related to governance, accountability, and global response coordination. Then in January 2026, the U.S. Department of Health and Human Services (HHS) issued a press statement confirming that the withdrawal had taken effect, and that U.S. participation and funding had ceased.

While these announcements do not alter hospital billing, coding, or reporting requirements, they signal a shift away from globally harmonized reference frameworks that have long influenced downstream interpretation.

WHO has historically served as a global reference-setter for disease definitions, surveillance frameworks, and clinical constructs used across research, analytics, and public health. Even when U.S. hospitals do not formally rely on WHO guidance, those definitions influence payer analytics, vendor logic, and retrospective review frameworks. As alignment with those global reference points weakens, interpretation becomes more variable.

That variability matters most after discharge, when the medical record becomes the salient representation of the patient’s encounter.

From a denial standpoint, policy discussions do not create new denial categories; documentation gaps do. When shared clinical framing becomes less consistent, payers rely more heavily on internal criteria, proprietary algorithms, and retrospective clinical validation. This expands payer discretion, particularly in areas already prone to disagreement, such as medical necessity, severity of illness, and acuity-based diagnoses.

In those situations, the question is rarely whether care was appropriate; the question is whether the documentation clearly demonstrates why the decisions were appropriate at the time they were made. When that explanation is implied rather than explicit, payers fill in the gaps. That is where denials originate.

It is also important to be clear about what is not changing. Under the current administration, the United States will not be adopting ICD-11. ICD-10-CM/PCS and CPT® remain the coding standards hospitals will continue to use. This is not a coding system transition; it is a documentation and interpretation issue.

This dynamic is not new, but it becomes more visible as alignment across definitions weakens. Conditions such as sepsis, acute respiratory failure, organ dysfunction, and short-stay admissions already are subjected to heavy scrutiny. As shared reference points shrink, documentation must do more of the explanatory work to limit reinterpretation.

This is where the work many clinical documentation integrity (CDI) leaders have already been doing becomes even more critical.

CDI sits at the intersection of clinical care, quality measurement, and revenue protection. By focusing on how severity, risk, and medical necessity are documented, CDI reduces the opportunity for payer reinterpretation and downstream denials. That role does not change when external standards shift. What changes is the extent to which documentation must independently support the clinical story after the patient leaves the hospital.

This work has never been about capturing more diagnoses. It is about ensuring that the clinical narrative is complete, defensible, and aligned with how claims will be reviewed retrospectively, most often by individuals and systems that were not involved in the patient’s care. Clear articulation of acuity, decision-making, and reassessment limits the payer’s latitude to apply alternative criteria after the fact.

In a more fragmented standards environment, documentation becomes the primary control mechanism hospitals have to manage denial risk. Clear timelines, explicit clinical reasoning, and documented risk assessment reduce ambiguity. Ambiguity, not disagreement, is what allows payers to substitute their interpretation for the provider’s.

Hospitals that have invested in documentation governance and CDI-led alignment across services are already positioned to absorb shifts in external standards without operational disruption. This includes alignment between CDI, utilization review, quality, and revenue cycle teams, as well as consistent expectations for how clinical reasoning is documented across service lines.

For organizations that consistently document severity, risk, and medical necessity contemporaneously and review documentation through a denials prevention lens, disengagement from global reference bodies does not introduce a new risk. It reinforces the importance of existing documentation strategies. For organizations that rely on assumed clinical understanding or retrospective clarification, the environment becomes less forgiving over time.

The impact is incremental, not immediate. There is no operational cliff. Instead, hospitals experience a gradual increase in denial complexity, audit friction, and documentation scrutiny if clarity is not maintained. Conversely, hospitals with strong documentation practices experience stability, even as external standards evolve.

When alignment shrinks, documentation carries more weight. That reality does not change coding systems or payment rules, but it does raise expectations for clarity and defensibility. Hospitals cannot control global standards, but they can control how clearly their clinical story is told.

References

World Health Organization. (2025). United States notice of withdrawal from the World Health Organization and effective date. https://www.who.int

The White House. (2025, January 20). Withdrawing the United States from the World Health Organization. https://www.whitehouse.gov

U.S. Department of Health and Human Services. (2026, January 22). United States completes withdrawal from the World Health Organization. https://www.hhs.gov