Effective clinical documentation is critical in order to accurately capture the high quality of care that your providers are giving.

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Quality

Get credit for the high-quality care you provide!

Effective clinical documentation is critical in order to accurately capture the high quality of care that your providers are giving. When documentation is compromised, an organization’s fiscal health as well as public perception can be jeopardized due to extraneously reported patient safety events and complications.

  • Our team approach helps your organization to achieve these objectives:
  • Ensure risk-adjusted mortality rates are accurate.
  • Capture and clarify diagnoses that increase risk for adverse outcomes.
  • Ensure accurate reporting of complications.
  • Review/clarify present on admission (POA) status.
  • Review/clarify significance of documented “complications”.
  • Review/ clarify use of “postoperative” when describing conditions in the post-op period.
  • Perform clinical validity for conditions such as postoperative respiratory failure.
  • Document specifically and thoroughly with clear cause and effect.

Patient Safety Indicators (PSI) and Hospital Acquired Conditions (HAC)

With hospitals facing a 1% penalty to revenue through CMS’s HAC reduction program, there’s more urgency now than ever to ensure your team understands how proper data capture and reporting of PSI/HAC can positively impact revenue. Consider this:

  • A 1% penalty for a large hospital is more than $1.1 million annually!
  • A 1% penalty for a mid-sized hospital is more than $600,000 annually!

Mortality Risk Adjustment Optimization

Documenting complete and accurate ICD-10 diagnoses is critically important to ensure capture of the severity of illness and risk of mortality of your patient population. In addition, the timing of the documentation is also important.

Only diagnoses that are captured Present On Admission (POA) are eligible for Medicare’s risk adjusted expected mortality. Optimizing your observed to expected (O/E) ratio is about documenting diagnoses effectively, as well as documenting these diagnoses in a timely manner to optimize your mortality metrics.

Contact us to begin getting credit for the high-quality care you provide.

Our Services

We break down departmental silos in hospital organizations through the unification of clinical documentation across quality, utilization, denials and CDI.

Physician Advisor Programs

Quality

  • Patient Safety Indicators
  • Hospital Acquired Conditions
  • Mortality Risk Adjustment Optimization

Utilization

  • Status Assignment
  • Medical Necessity
  • Extended Stay Reviews

Denials

  • Peer to Peer Support
  • Appeals Support
  • Contract Review

CDI

  • Documentation Education
  • Case Reviews
  • Query Support

LTAC Documentation

IRF Education

Speaking Engagements

Get Credit For The High-Quality Care You Provide!