Clinical Documentation
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The key to quality patient care and appropriate reimbursement
is complete and specific clinical documentation. The translation
of clinical documentation to coded data is never a simple
task. Whether services are acute care, rehabilitation or
psychiatry, most facilities have opportunities for documentation
improvement.
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Using a team based approach to facilitate improved documentation
your staff can be trained concurrently to enhance existing efforts
and coding through monitoring patient records for issues affecting
reimbursement. By bringing possible issues up to a physician during
the patient stay the need for HIM staff to query busy physicians
after discharge would be reduced and the quality of record documentation
can be improved, leading to improved care and more accurate reimbursement.
Data Analysis and Benchmarking
- Analyze data using PCS' Inpatient tool, SentinelTM
- Identify potential ICD-9-CM, HCPCS, coding and compliance
issues
- Benchmark data against peers for areas of opportunity and
potential concern
Medical Record Review
- Identify documentation, coding, discharge disposition and
billing issues
Customized Education
- Provide a team based approach to address, clarify and educate
coders on identified issues
Clinical Documentation Improvement Implementation (CDI)
- Develop a customized program that best fits your facility's
needs
- Educate providers to assure a successful implementation
of the program
- Monitor and report the impact of the CDI program
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