Aging A/R Recovery

Along with our other services, Coding & Billing Solutions is fast becoming a leader in Clinical
Documentation Improvement. CBS is working with clients to help them capture appropriate
revenue that would have otherwise been missed; we work in tandem with the coding team to
illustrate patients severity of illness and risk of mortality.Health systems invest a lot of
resources into the care of their patients. We help educate providers to accurately document
diagnoses their treating. Now, we would like to help your organization benefit from our expertise
in this critical area.

Clinical documentation improvement (CDI) is the process of studying the clinical documentation
in a patient’s medical records for completeness and accuracy. Proper CDI by a skilled
organization like Coding & Billing Solutions involves a review of a patient’s diagnosis, diagnostic
findings, and disease process to reveal what could be missing, under-coded or incorrectly
coded. Our CDI specialists have both clinical and medical coding backgrounds and have deep
expertise in identifying these gaps.

Although specialist consults, lab tests and diagnostic tests can also be housed in a patient’s
medical record, clinical documentation, as it relates to Clinical Documentation Improvement,
generally refers to the entries made by a medical provider or clinical staff member who is
responsible for the patient’s care during in-patient visits.
While the implementation of electronic health record (EHR) systems has streamlined many
aspects of patient care and claim submissions, medical providers still have responsibility for
maintaining the entry of clinical information concerning the care that they have provided to their
patients.

To help providers succeed in this task, Coding & Billing Solutions’ CDI specialists are
responsible for reviewing patient medical records to ensure that the documentation reflects the
specific current conditions of a patient to allow for accurate coding of their health status.