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The importance of obtaining accurate documentation of patient encounters is key to the financial strength of the hospital. Are you confident in your physician’s documentation? Is your organization earning its full reimbursement for services provided?
Heath care organizations often find that their current clinical documentation does not accurately reflect the care that was rendered; therefore it affects ongoing patient care, regulatory compliance, physician/facility profiles, legal protection and reimbursement. In light of Medicare Severity DRG’s (MS-DRG), detailed documentation and accurately capturing complications and co-morbidities (CCs) has made the CDI specialist’s role more important and demanding as ever. CDI Professionals review cases during inpatient stays and work collaboratively with physicians to ensure that medicals records are complete and accurate before discharge.
Below are all the possible areas you can pull information that can be used in the coding process.

Does you facility currently have a Clinical Documentation Improvement Program in place? If not, the CDI program is an essential program to the long-term health of the hospital. MAS offers full training of Clinical Documentation Improvement and will ensure that your staff is prepared to tackle implementing and effectively managing this program.
Contact us today!
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