I prioritize thorough chart reviews, leveraging EHR systems to identify gaps in documentation. Collaborating with physicians and coders, I provide education on documentation standards and coding guidelines. Regular audits and feedback loops ensure continuous improvement. Staying updated on regulatory changes, such as ICD-10-CM and DRG requirements, is crucial. By fostering open communication and using data-driven insights, I ensure documentation aligns with clinical accuracy and compliance standards.

When discrepancies arise, I conduct a detailed review of the medical record, comparing documentation with coded data. I collaborate with coders and clinicians to clarify ambiguities, ensuring alignment with coding guidelines. If necessary, I initiate queries to physicians for clarification. My goal is to resolve discrepancies promptly while maintaining compliance and accuracy, ensuring the integrity of the documentation and supporting optimal reimbursement.

I have extensive experience in CDI programs, including conducting retrospective and concurrent chart reviews, identifying documentation gaps, and educating providers on best practices. I’ve worked with interdisciplinary teams to improve documentation quality, ensuring it reflects the severity of illness and supports accurate coding. My focus has been on enhancing clinical and financial outcomes while maintaining compliance with regulatory standards.

I stay informed through continuous education, attending webinars, and participating in professional organizations like ACDIS and AHIMA. I regularly review updates from CMS and other regulatory bodies, ensuring compliance with ICD-10-CM, DRG, and other coding standards. Subscribing to industry newsletters and collaborating with peers also helps me stay ahead of changes impacting clinical documentation.

I tailor my approach to each physician’s needs, using real-world examples and data to highlight documentation gaps. I emphasize the impact of accurate documentation on patient care, compliance, and reimbursement. By fostering a collaborative environment and providing constructive feedback, I help physicians understand the importance of detailed and precise documentation in supporting clinical and financial outcomes.