We assist healthcare organizations in soaring to new heights by improving clinical documentation.
Clinical Documentation Improvement
In today’s inpatient and outpatient healthcare environment, thorough clinical documentation improvement is imperative in providing an accurate reflection of the severity of illness for the patient population not to mention accurate reimbursement. At Axea, we provide the following services to ensure your documentation allows your organization to soar! Our flexible solution to approaching documentation improvement allows for the implementation of a complete program or a limited scope of review and physician education.
- Identify top revenue producing services lines and review records for potential documentation improvement.
- Identify outpatient services transition to physician based to provider based and assess coding education needs.
- Provide interim Clinical Documentation Improvement staff as needed.
- Implement a complete Clinical Documentation Improvement Program to include, record reviews, physician education, and ongoing monitoring.
- Educate physician regarding the importance of physician documentation.
- Assist them in uncovering the nuances between physician documentation and the current reimbursement system and severity of illness rating.
- Review the documentation entered into the Electronic Health Record to ensure it is an accurate reflect of the patient’s condition.
- An organization’s data should provide a clear picture of the severity of a patient as well as accurate reimbursement.