We conduct retrospective, concurrent, and prospective reviews of clinical documentation to identify missing or unclear information, initiate physician queries, and recommend improvement opportunities—ensuring your documentation is accurate, complete, and ready for final coding.

Our Clinical Documentation Integrity (CDI) services include:

• Concurrent medical record reviews to support timely and accurate claims submission

• Proactive physician queries to clarify diagnoses, procedures, and clinical indicators

• Follow-up on unanswered or delayed queries to prevent documentation gaps

• DRG validation and resolution of POA discrepancies to ensure compliant and accurate reimbursement

• Physician education and training on documentation best practices, regulatory requirements, and query response expectations

These services collectively improve the accuracy of coded data, reduce claim denials, and support proper reimbursement while promoting a culture of clinical documentation excellence.