The importance of clinical documentation and coding has greatly increased. Clinical documentation is a record detailing a medical treatment, medical trial, or clinical test. These records consist of accurate, timely, specific diagnoses, and procedures that are translated into coded data to represent a patient’s clinical status. The coded data is then used for quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending. This is used in diagnoses only to obtain the coverage and medical background and will not persuade or lead to any diagnosis. Clinical documentation is at the core of every patient encounter and has become the foundation of patient health records.
As healthcare research becomes more invested in clinical documentation, it is critical that healthcare facilities require quality metrics that ensure accuracy, security and clinical quality for correct reimbursement and patient quality. It is important to provide clinical documentation improvement with trained specialists who should continuously be educated to compliment your organization and operational circumstances.
Our Comprehensive CDI Specialist:
- Evaluate the current state of CDI at your facility
- Identify current specific hospital needs and value gaps with chart reviews and interviews
- Track program success to establish credibility and engage physicians
- Educate your physician staff, facility leadership tame, CDI specialist and other HIM personnel
- Facilitate communication between your medical staff and HIM personnel to help achieve the right support for ongoing success and documentation accuracy
- Monitor client specific metrics for continual success with quarterly reviews and presentations
Additionally, it is critical to create patient registry functions for efficiency with maintaining healthcare information from all sources for an individual patient and for evaluating claims. Healthcare research has a significant dependence on clinical documentation and coding. This research includes information on social factors, financing systems, organizational structures and processes, health technologies, clinical data, and personal behaviors. All this information is gathered and transcribed as data and used in clinical documentation.
Clinical documentation has a direct impact on patient care by providing information to all members of the care team, as well as those who may treat the patient later. There are many rules and guidelines for clinical documentation and coding that must be followed to ensure a strong and accurate healthcare foundation. It is critical to adhere to the ethical standards and foundational guidelines of the medical coding industry with experienced staff who are both trained and certified in medical coding and billing.
How we Help:
- Centers for Medicare and Medicaid Services mandates for Medicare-severity diagnosis
- Related Group (MS-DRG) assignment.
- Accurate Present on Admission (POA) coding
- Case Mix Index
- Recovery Audit Contractor preparedness
- Compliant Query Process
Clinical Documentation is important for every patient encounter to measure clinical quality, security, and reimbursement. PETTIGREW Clinical Documentation Improvement for Hospitals and Health Systems assist in ensuring that clinical documentation is accurate, timely, and clearly reflects the services that are provided.
Clinical documentation has a direct impact on patient care by providing information to all members of the care team, as well as those who may treat the patient later. There are many rules and guidelines for clinical documentation and coding that must be followed to ensure a strong and accurate healthcare foundation. Therefore, you should refer to a professional clinical documentation improvement specialist to ensure the quality of your patient records and the overall healthcare experience.
At ECLAT Health Solutions, we adhere to the ethical standards and foundational guidelines of the medical coding industry. Our highly experienced staff are both trained and certified in medical coding and billing. We set ourselves apart by performing a thorough and efficient investigation on any problematic claim, working until the issue is identified and fixed promptly.