Patient Status Assignment with Medical Necessity and Documentation Education

We conduct patient status reviews for determining appropriate level of care. By applying the CMS Two-Midnight guideline, we can effectively determine appropriateness of observation or inpatient admission status. We evaluate the documentation using guidelines and clinical judgment to create a clinical picture of the patient and apply it to relevant admission criteria, CMS coverage and practice guidelines.

Uniquely, we take patient status reviews to the next level by providing both medical necessity and documentation education directly to providers to support inpatient status assignment with action words to support the level and necessity of the hospital care provided.

Physician Advisor Status Assignment Program (Remote and On-site)

We have a proven track record for assisting medical centers with developing and sustaining physician advisor programs. Our program is multi-faceted and is customizable to the needs of the medical center. Whether you need assistance with planning and implementing a physician advisor program for new or existing staff members, have an existing program that needs optimizing, or are looking to expand the program scope, we are available to support your initiatives.

Our tactics include both on-site and remote education, obtaining benchmark data to monitor and measure success, daily cases sent for concurrent/retrospective review by our physician advisors, and a monthly summary report that identifies continued opportunities for sustainable success.

Denials/Appeals Services

We review medical necessity and clinical validation denials to determine proper DRG assignment and/or whether medical necessity was present. We then organize, coordinate and formulate a letter of appeal using evidence-based medical literature. We assist in following the denial through to the second and third level of appeal, including discussions and negotiations with the ALJ (administrative law judge).

When a denied claim is received, timing is crucial to determine if your organization agrees with the auditor’s findings. We know that payers initially deny about 9% of hospital claims. We offer deep subject matter expertise in denials resolution and can help your organization recoup reimbursement earned for providing care. Whether you are looking for full outsourcing or as needed assistance, we are ready to partner with you to fight the toughest of status or DRG denials.

Peer-to-Peer Denials Assistance

Our physician advisors work with medical centers across the country and have established a valued, credible relationship with many of the health plan medical directors when providing peer-to-peer reviews. Once we receive a request from a client. we take over the resource intensive process of contacting the payor within 24 hours, coordinating and bringing to close a peer-to-peer review.

With insurance companies denying at an incredibly high rate, we have an 89% success rate in overturning denials when clients send the denials to us at the peer-to-peer stage. In the majority of the remaining denials, when the circumstances do not meet inpatient criteria, a peer-to-peer review is successful in establishing cause to rebill the cases as observation.

Physician-to-Physician Documentation Education

We use a unique and effective technique for educating physicians using their own documentation. In order to stay compliant with AHIMA guidelines, we review discharged patient charts and provide direct feedback, enabling physicians to learn documentation improvement opportunities specifically from their own charts. In turn, physicians learn to document appropriately to support the Severity of Illness (SOI) and Risk of Mortality (ROM) of patients. Physicians respond well to our documentation education because it is delivered by one of their physician peers.

Documentation Services – CDI

Our physician-to-physician CDI services educate providers on proper inpatient documentation to support optimization of the MS-DRG as well as quality metrics tracked closely by CMS, to create better CC and MCC capture rates and improve Case Mix Index (CMI). We communicate one-on-one, directly with your challenging providers on cases you identify as problematic. We use physicians’ own documentation to educate them directly to more effectively capture Severity of Illness (SOI) and Risk of Mortality (ROM) of their patients. We provide customized documentation tips that include reference links to evidenced-based literature for providers’ ongoing reference. Our client results include 10% improvement of CC and MCC capture rates.

Query Support

We help our clients tackle the ongoing challenges surrounding queries, including unable-to-determine and unanswered queries. We assist in formulating effective, compliant queries for your providers. Clients seek our support for their specific query concerns and we provide physician-to-physician documentation feedback to reduce the need for future queries.

Case Management Support/Utilization Review

Effective utilization of resources is a key component to a hospital’s well being. Our physician advisors provide concurrent admission and continued stay reviews, acting as a liaison between the hospital case management department and physicians to encourage efficient utilization of resources to optimize length of stay.

Speaker at CME Lectures or Association Meetings

Our physician advisors are available to deliver lectures on the topics below. Contact us to inquire about speaking engagements.

  • 30-Day Mortality Metric Optimization, Optimize O/E Ratio
  • Medical Necessity Documentation to Support Status and the Two Midnight Rule
  • Documenting to Reduce Denial Risk
  • CDI for the Anesthesiologist
  • CDI for the Cardiologist
  • CDI for the CDI Specialist
  • CDI for the ER doctor
  • CDI for the General/Vascular Surgeon
  • CDI for HCC Capture and RAF Score Optimization
  • CDI for the Hospitalist
  • CDI for the ID Doctor
  • CDI for the LTAC Physician
  • CDI for the Nephrologist
  • CDI for the Neurologist
  • CDI for the New Resident
  • CDI for the Non-Physician
  • CDI for the OBGYN Physician
  • CDI for the Oncologist
  • CDI for the Orthopedic surgeon
  • CDI for the Pediatrician
  • CDI for the Practicing Physician
  • CDI for Quality Improvement
  • CDI for the Radiation Oncologist
  • CDI for the Urologist
  • HCC Documentation Education
  • Outpatient CDI
  • Outpatient Managed Medicare Documentation Improvement
  • Two Midnight Rule

Focused Reviews

We assist medical centers with improving key performance metrics through our focused review services, which may be based on data analysis of identified gaps, internal monitoring of metrics or new clinical practice guidelines. Focused reviews can be customized by specialty, provider groups, individual providers, diagnosis, procedures or any other subset of areas needing concentration. Examples of our focused reviews include: by provider, abnormal troponin, mortality, sepsis and TKA. Demonstrated benefits have shown to increase case mix index, improve quality metrics and increase reimbursement.

LTAC Documentation

We educate providers and documentation specialists in the post-acute space to optimize the MS-DRG at the LTAC level of care. Our education includes high-quality documentation techniques to demonstrate severity of illness as well as the importance of documenting to support levels of lower care as compared to STAC documentation.

Inpatient Rehabilitation Facility (IRF) Education

We educate IRF physicians in documentation essentials to satisfy IRF requirements to support inpatient rehabilitation hospitalization. IRFs use a unique coding system called Case Mix Grouping (CMG). We educate physicians on this tier system that exists within the CMG coding system in order to support utilization of resources at the IRF level. Our on-site education includes: case-mix groups (CMG) tier optimization, Post Admission Physician Evaluation (PAPE) documentation, Individualized Overall Plan of Care (IOPOC) documentation, 60% rule compliance, compliant conditions, impairment group, medical necessity of admission and audit reviews.

ICD-10 Evidence Based Order Sets

We educate physicians on proper inpatient documentation to create better CC and MCC capture rates and improve case mix index (CMI). Our client results include 10% improvement of CC and MCC capture rates.

ICD-10 compliant medical documentation is essential to ensure that proper Severity of Illness (SOI) and Risk of Mortality (ROM) metrics are captured for all physicians.

Outpatient CDI is essential for educating physicians on proper documentation in order to capture Hierarchal Condition Categories (HCC) that supports outpatient severity. We review provider outpatient documentation to educate on proper diagnosis capture and ensure the elements of the outpatient note support Evaluation and Management (E&M) coding.