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Clinical Documentation Improvement

Dynamic Solutions to Meet Your Clinical Documentation Improvement Needs

CDI Staffing Solutions

UASI has a full complement of clinical staff who are experienced in clinical documentation improvement and knowledgable in MS-DRG/APR-DRG and coding documentation requirements. UASI CDI specialists perform the following duties on a short or long term basis:

  • Review of Medicare or all payor inpatient/outpatient medical records concurrently for accurate documentation.
  • Work collaboratively with physicians to ensure clinical information in medical record is present, complete, and accurately reflects patient severity.
  • Formation of physician queries to clarify documentation gaps to support the appropriate MS-DRG/APR-DRG assignment.

New Program Development

UASI will assist with a three phased approach that includes:

  • Assessment of your current practices
  • Implementation of the program through role based training/education and metric development
  • Ongoing follow-up and coaching through the initial twelve months of the program

Existing CDI Programs

UASI will evaluate existing CDI programs with the following:

  • A comprehensive program evaluation to identify program strengths as well as opportunities to improve and ensure maximum effectiveness
  • Ongoing CDI support with continuous feedback on productivity, physician response rates and other key indicators of success, as well as annual education and coaching
  • Customized training to allow staff to transition into a CDS role and refresher training for existing CDI specialists

Expanded CDI Services

UASI offers the following expanded CDI services:

  • ICD-10 documentation gap analysis and targeted ICD-10 training
  • Physician in-services, tracking and reporting
  • CDS training - boot camps, ongoing education, new hire training
  • Case Mix Analysis
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