Dedicated to Excellence in Health Care Management

Clinical Documentation Improvement

Clinical documentation is vital in the health care workplace. If documentation is inadequate, then the care provided cannot be fully coded. If care cannot be fully coded, then it cannot be fully billed leading to a lack of full reimbursement; despite the fact that full care was provided and negatively impacted hospital revenue. Failure to accurately document care provided is a significant threat to hospital revenue as well as compliance. In this light, clinical documentation improvement is a necessity and a critical part of the revenue cycle.

Applied Management Systems (AMS) staff are experts in the fields of documentation, coding, charge capture and reimbursement. We can manage, train and educate hospital staff regarding the importance of full, accurate clinical documentation and its potential downstream effect throughout the revenue cycle and ultimate impact on the hospital. AMS understands how clinical documentation improvement will determine hospital revenue and therefore we are able to assess current documentation processes and create an improvement map to ensure full and accurate reimbursement. We are also able to stay on and work with departments in order to assist in implementation of new practices.