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Clinical Documentation

Fight Back RAC

The key to quality patient care and appropriate reimbursement is complete and specific clinical documentation. The translation of clinical documentation to coded data is never a simple task. Whether services are acute care, rehabilitation or psychiatry, most facilities have opportunities for documentation improvement.


Using a team based approach to facilitate improved documentation your staff can be trained concurrently to enhance existing efforts and coding through monitoring patient records for issues affecting reimbursement. By bringing possible issues up to a physician during the patient stay the need for HIM staff to query busy physicians after discharge would be reduced and the quality of record documentation can be improved, leading to improved care and more accurate reimbursement.

Data Analysis and Benchmarking
  • Analyze data using PCS' Inpatient tool, SentinelTM
  • Identify potential ICD-9-CM, HCPCS, coding and compliance issues
  • Benchmark data against peers for areas of opportunity and potential concern
Medical Record Review
  • Identify documentation, coding, discharge disposition and billing issues
Customized Education
  • Provide a team based approach to address, clarify and educate coders on identified issues
Clinical Documentation Improvement Implementation (CDI)
  • Develop a customized program that best fits your facility's needs
  • Educate providers to assure a successful implementation of the program
  • Monitor and report the impact of the CDI program




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