Clinical Documentation Integrity (CDI) Education and Query Review Services
With complete and accurate clinical documentation driving quality metrics, accurate reimbursement, and performance-based contracting, getting physicians to improve their documentation is a critical priority. Our peer physicians work directly with your providers, identifying cases and trends where there is opportunity to improve documentation effectiveness and drive immediate revenue results.
Compliant Documentation Education
Our physician advisors educate hospital physicians on proper and effective documentation to support optimization of the DRG and quality metrics.
Use physicians’ own documentation
To provide direct education to capture medical necessity as well as severity of illness (SOI) and risk of mortality (ROM) of their patients.
That is focused on demonstrating quality to improve physician buy-in.
Provide customized tips
For documentation education that include reference links to evidence-based literature for providers’ ongoing reference.
We help hospital clients tackle the ongoing challenges surrounding queries, including unable-to-determine and unanswered queries. When clients seek our support for specific query concerns, we provide physician-to-physician documentation feedback to reduce future queries.
We assist hospital organizations to improve key performance indicators (KPIs) through our focused review services, based on the following factors:
gaps identified through data analytics
identified through internal metrics
of new clinical practice guidelines
by specialty, provider groups, individual providers, diagnosis, procedure or other subset needing concentration
Our Results Include
Increased case mix index through capturing comorbidities that were treated or monitored but not captured through accurate or complete documentation
Improved quality metrics by validating the presence or absence of accurate and complete documentation of comorbid conditions and complications
Accurate reimbursement through precise reporting and billing of comorbid (secondary) conditions that affect patient care in terms of requiring:
- Clinical Evaluation
- Therapeutic Treatment
- Diagnostic Procedures
- Extended Length of Hospital Stay
- Increased Nursing Care and/or Monitoring
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