Documentation Improvement Consulting Overview

Thorough Analysis

OptumInsight’s unique approach incorporates a case-mix analysis and thorough coding and documentation review, which serve as a foundation for a comprehensive education plan for care managers, coders and physicians. These efforts minimize the need for retrospective physician queries, decrease the days from discharge to billing, and enhance the overall revenue cycle.

Correct Clinician Documentation That:

• Is illegible
• Lacks clinical terms and modifiers
• Doesn’t indicate patient acuity
• Omits patient treatment response details

Review Coding Production

OptumInsight’s consultants evaluate coding production that might be improved by working through case management or utilization review staff to identify physician documentation improvement needs (in the medical record) while the patient is still in the hospital.

Complete and Accurate Documentation

Concurrent documentation provides a model for ensuring more complete and accurate documentation during each inpatient encounter. Consulting programs offer physician-specific education sessions that are customized by service line.