In emergency medicine, you assess the situation, determine a plan of action, and fix the problem. We use the same approach for your CDI, ICD-10, and E&M needs. It is not one-size-fits-all solution. We will customize a package for you.

The most popular services we provide are:

The only adult learning modules for clinical documentation designed by a MD for clinicians to absorb anywhere at their convenience, complete with CME. Guaranteed to permanently change perception of CDI and documentation behavior. Your patients and Case Mix Index will thank you!

  • Want to eliminate the need for consultants in the future? Seems counterintuitive, but I know I can’t be everywhere at all times. I will train your provider to be your physician advisor.
  • Group or individual training available

  • Case-based, engaging, dynamic, individualized presentations by experienced physician presenters with intimate knowledge of clinical medicine, documentation, CDI, and ICD-10.
  • Targeted presentations addressing your providers’ specific documentation needs, based either on your request (if you identify your problem yourself), or as per our medical record review findings. Available to do general educational Grand Rounds.
  • In-person is optimal, and you may record it if you so desire. By webinar is next best option. We can create sustaining modular materials on request.
  • We will perform a focused medical record review. The number of records, the assortment of DRG or providers will depend on your unique situation.
  • You will get feedback including suggestions for improvements in coding and opportunities for improvements in documentation.
  • You may choose to educate your providers yourself, or you may select one of our education services.

Dr. Remer will virtually attend CDI education via conference call. CDI team chooses topics (related to queries with improvement opportunities, coding updates, challenging clinical conditions) and prepares education. Dr. Remer contributes clinical perspective and adds coding/CDI insight. This activity has been extremely well received by participating organizations.

  • Affording the highest level of clinical expertise, medical record reviews are performed by Dr, Remer personally, in real-time. She will find coding, CDIS, and provider documentation opportunities.
  • Dr. Remer can help you select most promising second-level reviews to improve documentation, quality metrics, and reimbursement

We have a whole curriculum of documentation for trainees to ensure that they document for clinical communication, to support Evaluation & Management levels, for Medicolegal purposes, and Clinical Documentation Integrity. Attention is paid to avoidance of risky documentation practices, like copy and paste.

  • Specific documentation feedback to the individual provider with suggestions and supporting educational materials as needed
  • Redacted feedback for dissemination to service lines or medical staff
  • Coding feedback for specific ICD-10 conditions and DRG assignment
  • CDIS empowerment; clues to documentation opportunities, nonthreatening ways to engage the provider, development of compliant queries

The provider’s and his group or hospital’s interests will now be aligned as fee-based payments are eliminated and medicine moves to value-rewarded payment systems. We can train providers to give the specificity and to demonstrate acuity and severity to optimize payments.

Is your Risk-Adjusted Mortality Index suboptimal? Does it look like patients are unexpectedly dying? I can help put a process in place for you to optimize the documentation and coding of patients who expire.

Don’t see the service(s) you want? Ask us if we can provide it or refer you to someone else who can.