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Gain assuranceClinical documentation improvement and coding compliance

Essential elements for comprehensive coding and clinical documentation compliance

Proactive clinical documentation improvement and coding reviews are essential elements of any healthcare organization’s compliance plan. BerryDunn’s team includes nurses, health information management professionals, certified compliance experts, AHIMA- and AAPC-certified coding professionals and trainers, as well as revenue cycle experts that deliver comprehensive, accurate reviews and audits to ensure compliance with the myriad of payer and regulatory requirements.

Coding audits and reviews
Clinical documentation and coding audits and reviews performed by a qualified independent expert contributes to revenue integrity. BerryDunn conducts periodic and ongoing coding and documentation audits to identify improperly coded claims, the impact to revenue of inaccurate coding, and appropriate medical record organization. Our experts also work with counsel on reviewing government and payer audits. 

Coding reviews
BerryDunn’s Clinical Documentation Improvement (CDI) and coding reviews are revenue-integrity focused by confirming patient encounters are coded in a way that maximizes legitimate reimbursement. 

Our experts are skilled in:

  • CPT
  • DRG
  • ICD-10-CM/PCS
  • Evaluation and management
  • Risk-adjustment coding
  • HCC coding

Education and training
Separately or as part of a review, our consultants are available to present coding education and training for staff and providers, in addition to advisory services around documentation and coding best practices.

BerryDunn has joined forces with the VantagePoint Healthcare Compliance and Credentialing team to expand the services we provide to healthcare organizations. Contact us to learn more about our coding compliance services.

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