Physician-led CDI/DRGV is a relatively new phenomenon. Until roughly 10 years ago, coding, clinical documentation improvement programs, and DRG validation at hospitals were handled by internal auditing staff and nurses.

Then, big changes came to the healthcare industry. Government audits and payor denials increased. ICD-10 coding standards, which were more complex and specific, went into effect. Coding guidelines changed more frequently. The cost of doing business rose and hospitals struggled to receive full reimbursement for their services.

Bilal Mushtaq, MD, COO of Paramount Health Solutions (PHS), said, “Hospitals and health systems started to realize – why not support the work of the Clinical Documentation Improvement (CDI) nurses and coding staff with physicians with advanced clinical knowledge? Hire physicians and teach them about coding,” he explained. “That’s exactly how I got started in this industry. I had the clinical knowledge, but I had to learn the coding world.”

Dr. Mushtaq explained hospitals that partner with Paramount Health Solutions have the advantage of a second, supplemental review behind the hospital’s coding employees.

“When it comes to DRG validation, our review process goes beyond the typical coding and CDI workflow at the hospital level,” Dr. Mushtaq said. “Our reviews bridge the gap between the coding and CDI that is done at the hospital – because we’re looking at everything from a post-discharge, pre-bill perspective. Our deep audits focus on the integrity of the medical charts by identifying clinical documentation query opportunities and coding errors.”

Dr. Mushtaq and the other MDs at PHS have backgrounds as health system employed physicians specially trained in CDI/DRGV and coding program implementation. In addition, they have experience in the related areas of clinical validation of physician documentation, quality reviews, physician education, clinical decision support, denial management and revenue cycle operation management.

Their vast knowledge in these interconnected realms, along with their clinical expertise, empowers the PHS physician team to review charts in an optimal manner. “Full scope auditing” is the term they use for their process.

Wes Littrell, President and CEO of Paramount, said, “We supplement the hospital’s staff. We don’t replace anybody. That’s not what we do. We supplement their current staff with our physicians who have deep clinical knowledge and coding expertise. Most hospitals don’t have physicians with the experience and credentials to oversee or perform chart reviews. Our MDs review everything in the charts, resulting in exceptionally clean, accurate charts.”

Before a bill goes out for final billing, a PHS physician reviewer audits the patient encounter within the Electronic Medical Records system. Next, there is a validation process of auditing the coded ICD-10 CM and PCS abstracts against the documentation presented in the record. When over coding or lack of clinical significance is found, it is downgraded appropriately or queried. The team also scans the charts for coding errors and incomplete or missing documentation.

“Not only are we looking for opportunities to improve reimbursement, we also have that compliance hat on to make sure only appropriate diagnoses are being billed out and are being captured in a way that depicts the true clinical picture of a patient’s stay,” Dr. Mushtaq explained.

“All of our physicians are up to date on the codes and CDI. We focus on the details in every chart. We’re catching mistakes and identifying revenue opportunities for hospitals, as well as improving compliance and accuracy.”

Beyond chart review services, PHS provides ongoing training to hospital physicians, nurses and coding staff so they can play an active role in the hospital’s CDI processes.

To learn more about the full scope review process and our risk-free 90-day audit program, click here. You can also connect with a PHS expert online or call us directly at (615) 347-4867 or (210) 725-3444.