Our results include 10% improvement of CC and MCC capture rates and a case mix index increase to a record high of 2.0!

With complete and accurate clinical documentation continuing to drive quality metrics, accurate reimbursement and performance-based contracting, we recognize that getting physicians to change their documentation habits is a priority.

Through our physician-to-physician clinical documentation improvement (CDI) education and query review services, we communicate one-on-one, directly with your providers on cases that your team identifies as documentation concerns.

Documentation Education

We 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 use physicians’ own documentation to educate them directly to more effectively capture medical necessity as well as severity of illness (SOI) and risk of mortality (ROM) of their patients.

By keeping the focus in a clinical perspective, we are successful in getting provider buy-in. We provide customized documentation tips that include reference links to evidence-based literature for providers’ ongoing reference.

Case Reviews

We assist hospital organizations with improving key performance indicators (KPI) through our focused review services, which may be based on any the following factors:

  • Data analysis of identified gaps
  • Internal monitoring of metrics or new clinical practice guidelines
  • Customized by specialty, provider groups, individual providers, diagnosis, procedure or any other subset needing concentration

Our results include:

  • Increased case mix index through capturing comorbidities that were treated/monitored but not substantiated through accurate and/or complete documentation.
  • Improved quality metrics by validating the presence or absence of accurate and complete documentation of comorbid conditions and/or complications that affect the reporting of severity of illness and risk of mortality.
  • 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, or
    • Increased nursing care and/or monitoring

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.

Contact us to learn more about our CDI services.

Click on the services below to learn about our comprehensive clinical documentation education and revenue cycle management solutions.