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Our Enhanced Clinical Documentation Improvement Program

May 7, 2024
By: Laura Manser, CPC, CEMC, CPMA, CIRCC, RCC, Director of Provider Education

We are at an exciting juncture in our company’s history. Recognizing the critical role of clinical documentation in the delivery of high-quality healthcare, we are doubling down on our efforts to expand and enrich our Clinical Documentation Improvement (CDI) program. This initiative is not new to us; it has been a cornerstone of PBS’s commitment to excellence. However, we are now investing more resources and time than ever before to enhance this program. Our goal is to not only maintain but elevate the standards of documentation that facilitate accurate diagnoses that support medical necessity, improve proper reimbursement, and ensure compliance with healthcare regulations.

Given the challenges of the past few years, including Medicare radiology reimbursement reductions, a shortage of radiologists, and the hurdles posed by the flawed MIPS program, all of which have put considerable pressure on the field of radiology, the significance of achieving accurate reimbursement through proper report documentation has never been more critical. These circumstances highlight the crucial importance of our CDI program. Proper documentation stands as a beacon of control and certainty in an uncertain landscape, ensuring that your practice claims the reimbursement that accurately reflects the true value of the services provided.

Our CDI program is more than just a service; it is a value-added partnership. We are committed to working closely with you, our physicians and healthcare providers, to make clinical documentation a seamless part of your workflow.

Designed with our providers at the forefront, this enhanced CDI program aims to support you in navigating the complexities of medical documentation, offering the time, training, and ongoing guidance necessary to refine the documentation process. By enhancing documentation accuracy and completeness, we can reduce administrative burdens to the physicians, thereby enabling you to devote more attention to patient care.

As your Director of Provider Education, I am particularly excited about the opportunities this program presents for collaborative learning and improvement. Teaching and sharing knowledge are not just aspects of my job; they are my passion. Drawing from my previous experience as a coding manager, shaping our medical coding team through effective training and supportive learning environments, has reinforced my belief in the power of education. I am dedicated to extending this educational approach to our provider initiatives.

A few of our commitments to our clients are documentation reviews, quarterly accuracy and documentation audits, monthly feedback on medical necessity and denials, and education on report template optimization. Please don’t hesitate to reach out to me with coding or documentation questions, or to schedule a coding education and documentation review session for your providers.

I look forward to this journey with you, valuing your feedback, insights, and partnership as we aim to position our CDI program as a paragon of excellence in the healthcare industry. Together, let’s pave the way for a future marked by compliance, efficiency, proper reimbursement, and most importantly, exceptional patient care.

Warmest regards,
Laura Manser, CPC, CEMC, CPMA, CIRCC, RCC Director of Provider Education

 

Laura Manser CPC, CPMA, CEMC, CIRCC, RCC, is the Director of Provider Education at PBS Radiology Business Experts. With 23 years of experience in radiology, specializing in professional and hospital coding and auditing, Laura is a valuable resource for physicians and coding teams nationwide. She is dedicated to accurate and compliant medical coding and to developing clinical documentation improvement programs within radiology practices. Laura enjoys educating coders and physicians to enhance coding accuracy and documentation, optimizing revenue. Known for her proactive leadership, strong work ethic, and commitment to excellence, Laura holds multiple coding certifications from AAPC and RBMA. 

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