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Clinical documentation is the foundation of every patient encounter.  It influences quality reporting, provider report cards, public health data, reimbursement and disease tracking trends.  Coupled with clinical documentation improvement (CDI) and coding, improved provider engagement in documentation offers the opportunity to enhance reimbursement by accurately capturing patient acuity, reflected by the hospital’s case mix index.  As hospitals and health systems shift towards risk-based payments and an increase focus on quality measures and outcomes, documentation capture is increasingly more important and complex and must include initiatives to engage, partner and motivate your providers to document with greater accuracy and specificity. 

Improved documentation impacts both the hospital and providers by:

 

  • Driving appropriate coding and DRG assignment for accurate reimbursement
  • Improving accuracy of patient acuity levels – impacting relative weight, severity and ultimately CMI
  • Reducing compliance risks
  • Providing accurate data for quality and outcome measures (specifically observed to expected mortality indices and adjusted length of stay)
  • Reducing coding turnaround time and CDI work loads
  • Decreasing coding queries to providers – reducing provider burnout and improving clinical efficiencies

Our approach is to partner with organizations to assess and identify opportunities to increase documentation accuracy and specificity and align with providers to implement education, training and support programs that:

 

  • Identify themes of clinical documentation opportunity that impact DRG assignment and reimbursement; as well as impact, relative weight, severity and mortality. 
  • Motivate providers to document with greater accuracy and specificity while simultaneously reducing provider burnout.
  • Improve the collaboration between providers, CDI and coding.

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