Clinical Documentation Improvement (CDI) and DRG Validation (DRGV)

  • Clinical Documentation Improvement (CDI) is critical to capturing the true clinical picture of a patient’s stay. Proper and accurate documentation is essential for several reasons, including patient safety, accurately recording population health and claim submission.
  • Comparing or contrasting past and current encounters to validate diagnoses and treatment plans rests solely on documentation. Clinicians can use historical data in a variety of statistical analyses to establish evidence-based medicine and associated treatment protocols.
  • To obtain proper reimbursement for services rendered, drugs administered and other billable items, clinical documentation is paramount. The primary focus of clinicians is patient care. More time spent on documentation takes a physician’s attention away from patient care. Our team of Clinical Documentation Specialists (CDS) can help.
  • Our CDS crew is comprised of physicians and highly trained individuals who focus on the details in every patient chart. They review charts for information indicating exactly what was included in the patient encounter.
  • Our team looks for coding errors as well as incomplete or missing documentation.
  • Another important issue that is heavily impacted by improper and incomplete documentation is associated with Denials Management. If proper documentation has been done, the chart can easily be reviewed, and the claim can be appealed. Our expert teams are here to protect our clients with precision and accuracy.