McBee Clinical Documentation Improvement and Coding Services improve accuracy and quality, resulting in enhanced patient outcomes and optimized reimbursement.

Coding & Documentation Improvement

McBee clinical documentation and coding services help identify gaps in coding accuracy and track documentation trends. Our clinical documentation specialists partner with you to recommend and develop complete, precise processes that optimize reimbursement and improve your quality of coding and clinical documentation integrity. With McBee, you can address the underlying causes of medical record documentation to keep cash flowing, improve clinical outcomes and provide quality patient care.

Our monthly report packages include the consistency of accepting McBee recommendations, clinician error rates trends, case mix analysis as well as a question by question breakdown. Our reporting tracks trends for powerful clinical documentation improvement and increased clinical accuracy.

Utilizing McBee’s robust coding services and clinical documentation reporting, we target areas of concern, working with you to determine focus areas that optimize staff education. Our clinicians bring their average of more than 20 years of clinical documentation expertise directly to your team, ensuring streamlined clinical documentation processes in the long run.

Rest assured knowing that at McBee, each review withstands a rigid quality assurance process. Our CDI professionals maintain a minimum 97% accuracy rate, attend educational sessions, and are certified in OASIS-D, MDS, and ICD-10.

Clinical Documentation Improvement & Coding Services

Clinical Documentation Improvement FAQs

Clinical documentation improvement (CDI), also known as “clinical documentation integrity”, is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets (e.g. ICD-10-CM, ICD-10-PCS, CPT, HCPCS) sanctioned by the Health Insurance Portability and Accountability Act in the United States.

Accurate clinical documentation is a description of the patient that accurately reflects their condition, abilities, and environmental situation at that point in time. Clinicians must be sure documentation supports the developed plan of care, accurately describes patient outcomes, and reflects clinical competence.

  1. Lack of Documentation
  2. Electronic Medical Records without Narratives
  3. Not Interpreting OASIS Correctly
  1. A poor plan of care (too many visits, not enough reimbursement)
  2. Inaccurate patient health profile
  3. Potential for poor outcomes
  4. Flawed data set from which others may base their decisions
  5. Major financial challenges, such as lost revenue, ADRs and denials
  1. Prevents Compliance Issues 
  2. Creates Financial Burdens
  3. Creates Errors in Patient Status or Care 
  1. Wounds
  2. Sequela of cerebral injury
  3. Complications
  4. Neoplasms
  5. Mental disorders
  6. Neuro disorders
  7. Social Determinants of Health (SDOH)

Put simply, a CDS has to make sure all the information gathered and recorded is accurate and detailed. They may go through every piece of paper and every line of medical code for each patient’s case.  When it seems like information is missing, or there is conflicting data, it’s often up to a CDS to fill in the blanks. These situations require the CDS to communicate with various departments to make sure a patient’s records are as accurate and in-depth as possible.