Clinical Documentation

Cost, Quality, and Patient Experience

Since the implementation of the Affordable Care Act, medical documentation has become increasingly challenging. Providers must now ensure the medical necessity of services while simultaneously reducing liability for medical negligence through more efficient clinical documentation practices.

Utilization Reviews within the trifecta of Accountable Care Organizations (ACO) – Cost, Quality, and Patient Satisfaction – present significant obstacles for healthcare providers, regardless of their ACO status. We simplify this process by offering comprehensive onsite and offsite training, consultation, and support services customized for all types of providers.

Key Focus Areas in Effective Clinical Documentation:

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

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