Clinical Documentation Improvement

Clinical Documentation is at the heart of your medical administrative processes. Handling all this sensitive and crucial data with care and sense requires solid and secure systems and procedures.

QualCode helps organizations promote revenue integrity by ensuring that provider documentation accurately reflects patient severity and services rendered. We offer the following types of clinical documentation improvement (CDI) services: 

Inpatient CDI

If it’s not documented, it didn’t happen. Capturing every detail of patient care is paramount, yet busy providers struggle to document the level of specificity necessary for accurate code assignment. This includes looking beyond traditional complication and comorbidity capture rates to focus on quality. QualCode helps you address documentation gaps to ensure that documentation consistently reflects accurate and complete information for risk adjustment and value-based payments. 

Outpatient CDI

Risk-adjusted payment models require providers to capture patient severity and risk like never before. QualCode helps you improve hierarchical condition category (HCC) capture rates leading to more accurate risk adjustment factor (RAF) scores. Accurate RAF scores ultimately enhance revenue integrity, prevent recoupments, and mitigate compliance vulnerabilities.