The Healthcare Industry is experiencing the most radical and transforming change to date, with emphasis on physician documentation. In this era of Value Based Purchasing, RAC audits, Quality Initiatives and the implementation of ICD 10, the need for explicit documentation depicting efficiency and quality, that captures the patient’s true Severity of Illness and Medical Necessity, has never been greater. Proactively addressing the documentation of Present on Admission (POA), Medicare Severity-Diagnostic Related Groups (MS-DRG’s) and the significant risk factors involved in each and every diagnosis with specificity has become imperative, especially in meeting appropriateness of patient care and justifying consumption of resources.
DocuComp® LLC is committed to empowering healthcare professionals through innovative education and is pleased to offer educational solutions that meet your facilities goals, budgets and time constraints. In addition to our on-site programs, we will soon offer on-line programs that can be tailored to individual needs through live or on-demand presentations. Educational resources are provided to download for use, in conjunction with instructor presentation, to facilitate greater comprehension and retention. Interaction with actual case studies provides clearer understanding through “hands on” practice.
Educational topics can be further customized by time allotment that allows even the busiest clinician educational opportunities on critical, current issues. Post- review knowledge assessment is an integral component in all of our educational programs. We can add a survey to provide feedback regarding material relevance, instructor clarity, method of delivery and further topic suggestions, if desired.
Clinical Documentation Integrity Team Development & Implementation: We offer a clinical documentation improvement program that is all-inclusive hospital wide and advocates integrity in documentation. We bring together highly experienced, board certified physicians, nurses, coders and clinical documentation specialist who have years of clinical experience to educate the clinical documentation team and implement a program that is not limited to coding but focuses on documentation.
Physician-to-Physician Documentation & Medical Necessity Education & Implementation: We offer “peer-to peer” educational programs and updates on site and on demand to maximize the documentation of Medical Necessity, Severity-of-illness, Intensity of Service and Consumption of Resources.
Specialty Specific Clinical Departmental Education: We offer documentation education that covers the full spectrum of medical care in a specialty specific format. The diagnosis and management documentation content incorporated within our programs is appropriate to the clinical practice and the role of each specialty area.
Medical Record reviews for Clinical Documentation & Coding: DocuComp®, LLC offers documentation audit assessments that evaluate the explicit documentation of the physician and the accuracy of the coder to select and assign the appropriate codes based on that documentation.
Medical Necessity Reviews: Medical record reviews for medical necessity and determine how accurately documentation is capturing severity of illness, intensity of service and medical necessity to justify consumption of resources and quality patient care.
Compliance Reviews: Compliance in documentation and adherence to ICD-9, MS-DRG’s, CPT, HCPCS, APC, and E&M documentation and coding Methods/Standards are reviewed.
Clinical Gap Analysis Documentation Reviews: Conducting a gap analysis consists of reviewing current practices of clinical documentation by all clinicians, comparing current practices to “best practice” standards and principles of clinical documentation, undergoing root cause analysis outlining contributing factors, and ultimately developing and implementing a sound business plan for clinical documentation process improvement.
Physician Advisor Services education and implementation: provides education and onsite peer-to-peer mentoring to ensuring that each admission to your facility is accurate, appropriate in the correct setting at the time the decision is made to admit.
Inpatient vs. Outpatient Observation Status Determination Services, Education and Implementation: Provide an Onsite Mentoring multi-day program for Clinical Teams incorporating real-time case reviews, time on the clinical unit, and individualized review to improve screening review skill sets and physician documentation necessary each.
Utilization Review services and education: education and mentoring to ensure that the medical record documentation supports the level of care ordered by the attending. The Physician Advisor can also serve as a liaison regarding the increased regulatory focus on inappropriate admissions to the wrong setting, and improve documentation and communications with the Medical Staff.
Compliance Presentations & Updates for Administrators and Boards: DocuComp®, LLC stays abreast of all of all Centers for Medicare and Medicaid Services (CMS) regulations and updates that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. Presentations on these crucial issues can be online or onsite.
Evaluation & Management (E & M) Documentation Education: DocuComp® LLC physicians have years of knowledge and expertise to provide the “peer-to-peer” education practicing physicians need to document their practice of medicine.
Outpatient Ambulatory Care Documentation Education: DocuComp® LLC physicians understand and provide documentation education particularly with regard to the impact on documentation compliance within the new regulations on Outpatient Ambulatory Care.
Emergency Department (ED) Documentation Education: DocuComp® LLC provides education in evidence based criteria to help ED physicians determine the appropriate level of care admission.
ICD 10 Documentation Education & Implementation: By providing peer-to peer education, we teach our clients to implement explicit documentation within ICD-10. DocuComp® LLC offers a wide variety of ICD-10 educational programs that can be customized to meet individual budget and time constraints.
Case Management/Utilization Review Education: Case management and Utilization review work in tandem through comprehensive reviews of clinical documentation to assure the medical necessity of each patient’s level of care. Our team of physicians, case managers and coders provide onsite education and continuous review and recommendations to educate and update this team.
Professional & Motivational Speaking Presentations: Health care is in a rapid stage of transformation but there are solutions and proactive measures available to help smooth the transitions. Through presentations that define the educational and professional opportunities available today, we are able to encourage the health care community to excel in their professions and embrace this change.