Coding & CDI
At HealthRCM, medical coding and clinical documentation improvement (CDI) are at the heart of what we do. Our coders work closely with each client to understand their workflows, documentation practices, and coding requirements.
Over the years, we have worked across a broad range of outpatient specialties and care settings. We know that every organization works differently, so we adapt our coding processes and training to each client rather than taking a one-size-fits-all approach.
Our coding experience includes:
Urgent Care · Primary Care · Hospital at Home · Behavioral Health · Telehealth · Cardiology · ENT · Gastroenterology · Laboratory Services · OB/GYN · Oncology · Orthopedics · Pediatrics · Podiatry · Diagnostic and Interventional Radiology
Training
Good coding starts with good documentation. We work with physicians and other healthcare providers to help them understand how their documentation affects coding, compliance, and the revenue cycle.
Our training is practical and tailored to each organization’s specialties, documentation practices, and areas of concern. Rather than focusing on coding rules in isolation, we use real-world examples to explain what information is needed in the medical record, why it matters, and how documentation can be improved without adding unnecessary work for the provider.
Training is led by experienced, certified coding professionals and can focus on specific coding and documentation topics, audit findings, regulatory requirements, or broader revenue cycle education. Our goal is to make coding and documentation requirements easier to understand and apply in everyday clinical practice.
Auditing
Coding audits are an important part of maintaining accurate and compliant billing practices. We conduct medical coding audits to help healthcare organizations understand where they are doing well, identify areas that may need attention, and address potential compliance risks.
Our audits can be tailored to the needs of each organization, whether that means reviewing a specific coding or documentation concern, evaluating a sample of encounters, or providing ongoing quality assurance. We look closely at coding accuracy, clinical documentation, applicable guidelines, and regulatory requirements.
RCM Consultation
Revenue cycle management involves many interconnected processes, and problems in one area often affect several others. Our consulting work starts with understanding how those processes work together within each organization and where there may be opportunities to improve accuracy, efficiency, compliance, or financial performance.
We work with healthcare organizations to review their existing processes, identify gaps and recurring issues, and develop practical recommendations based on what we find. Depending on the organization’s needs, our work may focus on a specific part of the revenue cycle or include a broader assessment from patient registration through billing, payment, and collections.
Revenue Cycle Assessment
Our full revenue cycle assessment looks at the processes, systems, and controls that support the revenue cycle. We follow the flow from patient registration through final payment and review how the different parts of the process work together.
The assessment may include:
Process flow and design
Organizational structure and productivity – team structure, responsibilities, workflows, and productivity measures
Vendor performance and management
Patient registration – insurance eligibility, registration accuracy, prior authorization, and point-of-service collections
Coding and clinical documentation
Charge capture
Chargemaster management and compliance
Claims submission and clean claim performance
Payment posting and reconciliation
Payer contract management
Revenue integrity – collection rates and identification of underpayments and overpayments
Denial management – denial rates, common denial reasons, and related workflows
Accounts receivable aging
Self-pay processes and strategy
Reporting and analytics
Technology – use of EHR, practice management, billing, and other systems that support the revenue cycle
At the end of the assessment, we bring the findings together to help the organization understand what is working well, where problems or inefficiencies exist, and which areas may benefit from additional attention. Our recommendations are practical and take into account the organization’s existing team, workflows, systems, and resources.