Services

Clinical Documentation Improvement

YOUR KEY TO ACCURATE PAYMENT IN THE AGE OF ACCOUNTABILITY

OUR CLINICAL DOCUMENTATION TRAINING AND SUPPORT SERVICES ARE DEPENDABLE, RESPONSIVE, AFFORDABLE AND PHYSICIAN-FRIENDLY

 

HCRS documentation checklist for physicians

As hospitals, physicians and payers have prepared for ICD-10 implementation, everyone has been repeatedly told that ICD-10 CM and (especially) PCS require more detailed and accurate documentation than did ICD-9. How big is the difference? A study conducted last year showed that only 27% of a sample of medical records across the country coded in ICD-9 provided enough detail to be “coded out” in ICD-10 rather than coded with “Not Otherwise Specified,” “Not Elsewhere Classified,” or “Unspecified.”

 

And it’s not just the advent ICD-10 that will be requiring physicians and hospitals to be specific, complete, accurate, legible and evidence-based in their approach to documentation. Quality and Value-Based Purchasing (VBP) programs from CMS and other regulators use risk-adjusted metrics whose scoring takes into account the disease burden of the population whose outcomes are being measured. To the extent that its coding is not precise or comprehensive enough to fully represent the population’s disease burden, a health system, hospital, physician group or Accountable Care Organization (ACO) risks foregone bonus payments and increasingly-painful penalties.

HCRS offers clinical documentation improvement (CDI) specialists selected for both their technical and their interpersonal skills. They work extremely well with physicians, coders, and internal CDI specialists. We offer:

Our  proprietary Physician-FriendlySM clinical documentation training, which is:

  • Designed based on behavioral research that takes into account what motivates physicians.
  • Customized to your high-dollar, high-frequency diagnoses and procedures.
  • Workshop-based – physicians learn as they practice
  • Adaptable to work with on-line training
  • Compatible with all CDI software

Ongoing CDI audit, coder training and assistance to make sure that the query process works smoothly and that CDI specialists, coders and physicians are communicating and coordinating effectively.

 CALL US AND LET US TELL YOU MORE!!