CDI Support
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.
Get credit for the high-quality care you provide
Effective clinical documentation is critical to accurately capture the high quality of care that your hospital provides. When documentation opportunity exists, an organization’s fiscal health as well as public perception can be jeopardized due to innappropriate reporting of patient safety events and complications.
Our clinical physician advisors can help
Capture and clarify diagnoses that impact quality metrics
Review and clarify present on admission (POA) status
Ensure accurate reporting of Severity of Illness (SOI) and Risk of Mortality (ROM)
Ensure risk-adjustment methodologies are optimized
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.
Provide education
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.
Query Support
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.
Mortality Risk Adjustment Optimization
Documentation and coding of all reportable ICD-10 diagnoses is critically important to ensure accurate portrayal of risk. In addition, many quality metrics only utilize diagnoses captured as Present On Admission (POA) for risk adjustment. These risk models are often very complex and require an appreciation of the methodology to effectively optimize Observed to Expected (O/E) ratios.
Our team has deep knowledge of multiple risk models and can work with your organization to guide your team and teach your providers.
Case Reviews
We assist hospital organizations to improve key performance indicators (KPIs) through our focused review services, based on the following factors:
Documentation
gaps identified through data analytics
Opportunities
identified through internal metrics
Application
of new clinical practice guidelines
Focus
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
The Purpose of CDI
It supports the reporting of quality metrics, aiding in the evaluation and improvement of healthcare outcomes.
It promotes compliance with regulatory guidelines and standards, mitigating potential risks and liabilities for healthcare providers.