Clinical Documentation Improvement

A Collaborative Approach. Ask questions. Gather critical data. Ensure project success.

Universal Coding Solutions Health Information Management (HIM) / Clinical Documentation Improvement (CDI) services provide you with the ability to build the necessary foundation to emphasize specificity in your medical records documentation.

We work with each client to satisfy their particular needs and offer customized solutions that ensure responsiveness and accountability. The outcome of more accurate coding and better reimbursement as well as reporting for both physician and hospital will result in improved quality which is our desired goal.

Universal Coding Solutions is your trusted and dependable resource to help resolve documentation gaps and to address:

  • Centers for Medicare and Medicaid Services (CMS) mandates for Medicare-severity diagnosis
  • Related Group (MS-DRG) assignment
  • Accurate Present On Admission (POA) coding
  • CMI (Case Mix Index)
  • Recovery Audit Contractor (RAC) preparedness
  • Compliant Query Process.

Our Comprehensive CDI Specialists:

  • Evaluate the current state of CDI at your facility
  • Identify current specific hospital needs and value gaps with chart reviews and interviews
  • Track program success/trends to establish credibility and engage physicians
  • Educate your physician staff, facility leadership team, CDI specialists and other HIM personnelFacilitate communication between your medical staff and HIM personnel to help achieve the right support for ongoing success and documentation accuracy
  • Monitor client specific metrics for continual success with quarterly reviews and presentations

Let’s Get Started …