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Chart Review

Effective and complete clinical documentation is paramount to healthcare delivery, serving as a communication tool for physicians to report and reflect their observations, recordings, tabulations and clinical impressions that accurately include their clinical judgment, medical decision making and thought processes. The life cycle and all the ancillary functions and roles integral to the revenue cycle are directly dependent upon the completeness and accuracy of clinical documentation that best communicates the care provided. Physician consistent adherence to best practice standards and principles of documentation properly aligns and supports achievement of a high performing revenue cycle with optimal net patient revenue through reduction of avoidable medical necessity denials and financial recoupments from third party payers.

Core-CDI will conduct a complimentary inpatient medical record chart review consisting of 25 charts associated with known high risk DRGs. The chart review will consist of 20 inpatient medical records and 5 inpatient medical records denied for medical necessity. Each record will be thoroughly reviewed for the following attributes:

 

  • Accuracy and completeness of clinical documentation depicting, reporting, reflecting and describing of the patient story in support of medical necessity for inpatient admission

  • Quantification and qualification of medical necessity establishment and any potential concerns including risk of recoupments for lack of clear medical necessity

  • Accuracy and completeness of progress notes and discharge summary in support of continued stay and coordination of post discharge care

  • Clinical accuracy of ICD-10 code and DRG assignment using official coding guidelines and Coding Clinic advice and guidance

  • Extent and degree of undercoding and overcoding quantified

  • Missed opportunities for valid queries

  • Missed opportunities for higher severity DRGs related to insufficient and/or incomplete medical record documentation

  • Quantification and qualification of any other potential concerns.

  • Extent to which insufficient and/or poor documentation contributed to medical necessity denial

 

Client will receive an encompassing report with outline of findings by chart with calculated potential financial risk and/or financial opportunities by chart as well as a whole for all charts reviewed. A detailed management action plan will be an integral part of the encompassing report including recommendations that Core-CDI can help implement to address any identified issues and opportunities for improvement, driving revenue integrity in support of optimal net patient revenue.

 

Complete the request for assessment information below to get started on this highly beneficial complementary chart review analysis with report of findings and action plan.

Assessment Information
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