Clinical Documentation Improvement Services
Precise clinical documentation is integral to every patient encounter, as it assists providers to make informed decisions for patient care, helps assess clinical quality and determines appropriate reimbursement. A clinical documentation improvement program is a process designed and implemented with the purpose of achieving accurate and thorough medical record documentation.
At CureMed Solutions, we provide the support and expertise needed to comprehensively assess the patient’s documentation and also ensure that it is translated into accurately coded data enabling our clients eliminate gaps in their documentation and improve reimbursement considerably.
Our CDI programs are undertaken by clinically skilled healthcare professionals with multiple years of experience, who undergo extensive training on the process and also continued education. Our CDI specialists:
- Identify potential issues associated with patient documentation such as those related to medical necessity and requirement of supporting documents at the same ensuring all conditions that are clinically supported are reported in the documentation.
- Review all relevant medical records including clinical notes, diagnostic exams, lab results, and prescriptions to assess for any inaccuracies within the patient’s documents or possibility of any missed/under-coded diagnosis to ensure the level of service rendered is appropriately recorded.
- Effectively collaborate with the providers and the coders, working side-by-side with the team to aid in streamlining your coding efforts, reducing errors and time needed by the coders.
- Provide recommendations on improvements in documentation for further patient encounters as well to ensure better patient outcomes, data quality and prevent missing charges.
- Provide training and education to your clinical staff to identify gaps and reduce denials through a better documentation process.
