Challenges of Clinical Documentation

Almost all reimbursements in the healthcare industry are dependent on documentation of clinical and quality activities in the medical record. Therefore, each healthcare provider, hospital, and provider group should be well versed in how to document the following accurately:

  • Evaluation and Management (E&M) Services
  • Procedures and Non-E&M Services (CPT)
  • Diagnoses (ICD10)
  • Diagnostic Related Groups (DRGs)
  • Hierarchical Clinical Conditions (HCCs)
  • Quality of Care Measures (CMS – MSSP, MIPS, APMs, JC Standards)
  • Present on Admission (POA)

Assuring this happens requires a robust clinical documentation improvement (CDI) program, and Coker Group can help you build such a program that includes the following key elements:

  • Baseline education and updates for all providers
  • Routine audits of clinical documentation activities (inpatient and outpatient)
  • Adoption of IT systems that can support this complex task
  • Hiring and training of clinical documentation support staff that can work hand-in-hand with your providers to assure your CDI program functions smoothly and effectively
  • Selection of CDI outcome measures that allow you to monitor the CDI program’s effectiveness and efficiency over time
  • Responding to audits that will inevitably occur with even the best organizations

Contact us today for more information on the above clinical documentation services and to speak with Rosalind Cordini, Senior Vice President.

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