Clinical Documentation Improvement

Maintaining consistency in the accurate, timely and complete capture of physician documentation has a direct effect on reimbursement efforts. Managed Resources has a national network of Clinical Documentation Improvement (CDI) specialists who support the improvement of physician documentation to reflect the severity of illness and risk of mortality of patients across all areas and payers.

Our CDI service assists organizations to improve documentation processes and policies, and provide expert recommendations in implementing successful CDI practices.

Our CDI service delivery includes:

• Concurrent or retrospective reviews of health records to identify opportunities for improvement in the overall quality of clinical documentation
• Clarification of clinical documentation to ensure complete and compliant documentation that reflects the level of service rendered and medical necessity
• Identification of inappropriate admission, unnecessary stay and quality concern cases
• Continuing education and best practices on querying and documentation
• Collaboration with coders to ensure documentation of all known comorbidities/complications (CCs) or major CCs on the DRG Coding Abstract
• Identification of trends, growth, and gaps in diagnoses and procedures