Clinical

Clinical Documentation Improvement

Our solution significantly improves clinical documentation, ensuring that it fully and accurately reflects the severity of illness, complexity of care, and resources consumed. Our comprehensive program bridges the gap between clinicians and the coding and billing system, increasing CMI and capturing appropriate reimbursement for services provided.

What Sets Us Apart
Our Clinical Documentation Improvement team brings more than 30 years of collective experience to every engagement. Our team is 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 work collaboratively to design a comprehensive clinical documentation program, transfer the knowledge needed to achieve organizational goals, and provide follow-up services to ensure sustainability.

Our depth of experience in documentation improvement results in more compliant documentation, a more appropriate case mix index, and improvement in third-party cost and quality profiles. Our commitment to results and our ability to work collaboratively in any hospital environment allows us to consistently exceed client expectations.

A Comprehensive Approach
Accurate, complete, and specific clinical documentation has become increasingly critical in a wide spectrum of areas, including compliance with regulations, managed care profiles, payment for services rendered, and liability exposure. The transition to the new MS-DRG system has made accurate, comprehensive documentation and coding even more imperative.

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 severity of illness sufficiently to obtain full credit for all services rendered. The implications to both compliance and payment are significant for the hospital as well as the physician.

By focusing on both compliance and appropriate payment, our solution enables physicians and caregivers to bridge the gap between clinical and coding language and obtain recognition for the work effort, resources consumed, severity of illness, risk of mortality, and complexity of care.

Our solution includes training for individuals with key roles in clinical documentation improvement including physicians, dedicated clinical documentation specialists, and coders. We design a customized day-to-day workflow process for the clinical documentation team.

In addition, we track, monitor, and provide comprehensive reports to the clinical documentation team, physicians, and administration. The result is more accurate and timely coded data and the most appropriate DRG assignment.

Clinicians and coders trained in our program work together with the patient care team, case managers, quality associates, and the Health Information Management (HIM) department coding staff to identify opportunities where the medical record documentation can be strengthened or clarified.

Finally, we stay closely involved following implementation to ensure ongoing sustainability of the solution. This includes ongoing monitoring and evaluation, suggested adjustments, as well as continuing education to ensure your team stays up to date with the latest regulatory guidelines and new opportunities to improve documentation.

Unmatched Results
Wellspring+Stockamp’s comprehensive clinical documentation solution typically provides a 4 percent to 8 percent increase in CMI and a five-year return on investment of 6:1 to 10:1.

In addition to maximum compliant reimbursement, benefits include improved physician and hospital quality and financial profiles.

Show all professionals that specialize in Clinical