Clinical Documentation Improvement Services

Clinical Documentation Improvement Services are for hospitals, health systems, and physician practices who want to identify missing charges and improve documentation accuracy.

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Accurate Clinical Documentation


Improve your coding accuracy to optimize your reimbursement. Our comprehensive services help you reduce missed charges and denied claims.


Improve clinical documentation and flag missing or incomplete charts in real-time for faster resolution.


Identify coding trends, growth, and gaps in diagnoses and procedures.


Identify missing charges to help optimize revenue and reduce the impact of negative cash flow.


Improve diagnosis capture and ensure the level of service rendered is appropriately recorded.


Improve staff productivity by providing education and best practices on querying and documentation.

Improve Clinical Documentation and Charge Capture


Documentation accuracy

  • Conduct a complete assessment of your clinical documentation to identify any coding and process errors. Our team can then work with your physicians and clinical staff to educate them about how to address and fix any issues.
  • Inform your staff in real-time when missing or incomplete charts are flagged so coding errors can be resolved faster. Addressing the issues quickly improves your revenue cycle and cash flow.
  • Concurrent or retrospective reviews of health records and documentation best practices help you improve overall coding accuracy to prevent negative cash flow.
  • Identify coding trends, growth, and gaps in diagnoses and procedures to understand your current state and enable better business decisions for the future.

Staff support and education

  • Improve staff productivity by helping your team manage denials more effectively and by reducing physician and clinical staff coding errors and process issues.
  • We work with you to promote collaboration between physicians and other team members with coding accuracy and general process improvements.
  • Provide your clinical staff with education based on gaps to improve coding accuracy and reduce denials. Our support staff can help your team implement best practices for querying and documentation.
  • We provide interim Clinical Documentation Improvement (CDI) leadership, program development, consulting, and education to help optimize staff productivity and facilitate accurate clinical documentation.

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