Discover how to achieve accurate, patient-specific documentation.

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The key to accurate home health clinical documentation

One of the goals of the Patient-Driven Groupings Model (PDGM) is to put the focus on patient needs rather than volume of care. It relies more heavily on patient characteristics for payment than ever before. Reviewing your clinical documentation should be at the top of your list of clinical strategies for success under PDGM.

When you choose us to manage your home health clinical documentation review, you’ll have the confidence that while you focus on quality patient care, our experts are focused on speed, accuracy, and compliance.

Accurate, fast home health clinical documentation review

HEALTHCAREfirst helps home health agencies improve their clinical documentation so they can rest assured they are compliant, their reimbursements are accurate, and cash flow is optimized.

Achieve regulatory compliance

As clinical documentation responsibilities become more complex, you should be looking for cost effective ways to alleviate burdens so you can continue to focus on your mission of providing quality, patient-centered care. Our clinical documentation review experts have the knowledge and experience necessary to help you overcome documentation challenges and set you on a course for success.

Reduce your risk of errors

Under PDGM, your OASIS responses determine functional impairment groupings, so accurate data is essential for accurate payment. Our team of experts are highly skilled on OASIS competency so you can rest assured that your documentation is precise, patient-specific, and error-free.

Maximize reimbursements

A solid clinical documentation review process is essential to making sure that you get paid for the services you provide. If you don’t have a solid document review process, are worried about the additional manpower that may be required for review, or simply don’t want the extra burden, we can help.

Start of Care (SOC), Resumption of Care (ROC) & recertification OASIS review

  • Review of the patient chart including the SOC, ROC, or recertification OASIS assessment, physician orders, care plans, and visits to uncover inconsistencies and errors in the OASIS
  • Based on our evaluation, we make recommendations for corrections/updates to the OASIS
  • OASIS review experts are specialists in home health clinical documentation and are always up-to-date on the latest regulations and requirements, including OASIS-D and PDGM
  • Ongoing program evaluation with regular communication between our clinical documentation review team and your agency
  • We can log into your software system, no matter what EMR you use
  • Fast turnaround enables maximum reimbursement in a prompt manner
  • Web-based analytics offer insight into timeliness of claims, clean claim rate, and more

Plan of Care (485) review

  • We compare the SOC or ROC OASIS assessment and the 485 with the medical record and clinical documentation, including therapy evaluations and application of ICD-10 codes, for accuracy and consistency
  • Review documentation and provide suggestions to assessing clinicians via the HEALTHCAREfirst 485 Review Report for possible updates to the OASIS and 485
  • Coding suggestions can be entered into your EMR software
  • Regular communication and program evaluation between our clinical documentation review team and your agency
  • We manage the Plan of Care Review directly within your EMR, regardless of what system you use
  • Rapid turnaround time
  • Web-based analytics offer details about timeliness of claims, clean claim rate, and more

Discharge OASIS review

  • We compare the Discharge OASIS assessment with the most recent SOC or ROC to evaluate the OASIS-based outcome and process measures to determine if there has been an improvement or decline in the patient’s status
  • Based upon our evaluation, we provide suggestions for corrections/updates to the Discharge OASIS items
  • You benefit from regular communication and program evaluation between our clinical documentation review team and your agency to address any issues or discuss ways to improve
  • We work directly in your EMR, no matter what system you use
  • Fast turnarounds so you can keep you revenue cycle optimized
  • Web-based analytics including timeliness of claims, clean claim rate, and more

Learn what every home health agency should be doing to achieve OASIS accuracy.