IAS Clinical Documentation Improvement services focus on long-term success. Our team brings more than 50 years of collective experience to every engagement. We are composed of physicians, clinicians, and coders who are experts in the MS-DRG system and in the tools, strategies, systems, and skills needed to achieve the most accurate documentation and coding.
We customize our Clinical Documentation Improvement service based on priorities identified by the client and collaboratively tailor solutions to each facility’s specific needs.
IAS programs are designed on a case-by-case basis, never falling into a uniform approach.
Do you need a Coding Audit or a Clinical Documentation Improvement Program?
Accurate documentation of patient encounters is key to the economic health of physician practices and healthcare organizations. As regulations evolve to reflect advances in medical care and the ICD-10-CM/PCS implementation draws near the documentation process will become even more complex and vital to the financial health of the organization. Many consultants do coder accuracy audits they needed a Clinical Documentation Improvement Audit and support. In this era of ICD-10 transition, CERT, RAC, liability exposure, focus on medical necessity documentation, as well as enhanced governmental and payer oversight, we all need to objectively review our performance. The only way that healthcare organizations can survive is to ensure that the coding is complete, accurate and that the specific clinical documentation accurately reflects the severity of the illness and services provided. The industry is demanding a shift in process with a strong focus on quality.
Why isn’t a Coding Audit Alone Enough?
Typically, a broad gap exists between terminology used by clinicians and the terminology of coding and billing systems. As a result, physicians and hospitals frequently do not document the severity of illness sufficiently to obtain full credit for all services rendered. Coding audits that merely identify if the codes assigned to any case capture the words written in the chart do not take into account those clinical aspects.
Clinical documentation and coding audits are best performed with a collaborative team of clinicians and expert coders вЂ“ a clinician who knows the coding rules and a coding specialist who understands clinical documentation. International Alliance Solutions Clinical Documentation Audits are just that вЂ“ examination of the record of the patient’s interaction, with the provider’s delivery of that medical care. We analyze the diseases the patient has coming through the door, the conditions that get worked up and linked or not to the presenting symptoms.