Clinical Documentation

Cost, Quality, and Patient Satisfaction

Since the implementation of the Affordable Care Act, medical documentation has posed greater challenges than ever before. Providers must now ensure the medical necessity of services while also mitigating liability for medical negligence through smarter clinical documentation practices.

Utilization Reviews under the trifecta of Accountable Care Organizations (ACO) - Cost, Quality, and Patient Satisfaction - present significant challenges for healthcare providers, regardless of their ACO status. We simplify this process through comprehensive onsite and offsite training, consultation, and support services tailored for all types of providers.

Significant Areas in Prudent Clinical Documentation:

• Prepayment and Post-payment Audits: Focus on the appropriate use of modifiers such as 25, 59, and 91. The introduction of new modifiers (XE, XS, XP, XU) underlines the complexities of clinical documentation.
• Compliance and Audit Focus: Office of Inspector General (OIG) Programs ensure providers adhere to National Correct Coding Initiative (NCCI) edits and avoid inappropriate modifier usage.
• Evaluation and Management (E/M) Coding: Expert Clinical Documentation Improvement (CDI) specialists facilitate accurate E/M coding and determination of EM levels, ensuring compliance and optimal reimbursement.

Our team of certified specialists enhances provider capabilities in navigating these challenges, promoting compliance, and improving overall operational efficiency.