Clinical Documentation and Coding

Accurate documentation and Diagnosis Related Group (DRG) coding is a top priority for every hospital. It mitigates vulnerability to Medicare audits, improves quality performance scores, and prevents revenue leakage.

Inpatient documentation and coding are in the spotlight as the healthcare industry shifts toward value-based payment systems. Pressure is growing for hospitals and health systems to implement reliable solutions to promote enhanced accuracy.

Versalus Health offers three delivery models to improve CMI capture:

1) Clinical Documentation and Coding Improvement Program
We perform targeted prebill reviews coupled with case-level and trend-level education and analytics to improve the performance of your own teams while optimizing revenue and mitigating compliance risk.

2) Prebill Review Services
We perform high volumes of prebill reviews for you

3) Retro Review Services
We perform retrospective/post pay reviews to identify additional revenue opportunities.


Clinical Documentation and Coding Improvement Program

Versalus Health assists hospitals and health systems by providing hospital leadership with comprehensive analytics, in-depth education for physicians, and HIM and CDI professionals, and conducting case reviews to drive improvements in clinical documentation, coding, and reimbursement. Our program helps our clients develop high-performing CDI and coding teams.

Our programmatic approach has four components:

  1. Comprehensive assessment
  2. Data Driven Case Reviews
  3. Education
  4. Performance Improvement Analytics

Comprehensive Assessment

We begin by identifying appropriate cohorts for each facility in your system, interviewing your HIM and CDI line level leaders to understand your team structure, process, and technology, conduct a Baseline Performance Analysis, and perform case reviews to validate the financial opportunity identified.


Data-Driven Case Reviews

Auditing all cases within a DRG, or randomly selecting cases for audit, results in too many reviews and a low ROI. We use our proprietary benchmarking tool to monitor CMI performance along with our diagnosis code-based rules engine, to target reviews of cases that warrant them – those with actual revenue or compliance impacting opportunities.

 We conduct comprehensive prebill reviews, which seamlessly integrate with existing CDI and coding processes, as part of our broader Clinical Documentation and Coding Improvement services and we conduct retro reviews as a stand-alone offering to recover missed revenue opportunities.


Audits alone don’t improve CDI and Coding performance. Education around root causes is required. Clients use our case-level audit findings to educate individuals involved in the initial documentation and coding.

Additionally, we analyze the data from our case findings to identify error trends and topics for in-depth education. The education contains information for each constituent of the revenue cycle – physicians, clinical documentation specialists, HIM and Denials professionals.

Performance Improvement Analytics

Versalus Health’s Clinical Documentation and Coding Improvement Program leverages data analytics to focus reviews on the right cases, identify root causes, and educate your clinical and coding teams. The result — a solution that lowers compliance risk, improves quality metrics, and optimizes revenue. Our Clinical Documentation and Coding Improvement Program provides the best ROI for hospitals and healthcare providers looking to improve the performance of their own teams while optimizing revenue and mitigating risk during the process.


Optimize your organization’s clinical revenue cycle performance.


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Learn how Versalus Health’s innovative appeal solutions can drive increased revenue for your hospital.

Physician Advisors

Physician Advisors

Today’s hospitals and health systems require physician clinical expertise tied to in-depth knowledge of documentation best practices, length of stay management, quality, contracting, billing, and compliance, among other disciplines. Hospitals and health systems have invested significantly in building internal Physician Advisor teams to address these needs.

Regulatory Compliance

Regulatory Compliance

Regulatory compliance is a complex issue for many healthcare facilities, especially as new, updated regulations supersede old ones. Hospitals and health systems may find it challenging to stay up to date with regulatory changes impacting Utilization Management (UM) and the clinical revenue cycle and determine the implications of these regulatory changes on the organization’s processes. Fortunately, Versalus Health can assist your organization with keeping up to date with regulatory changes. We keep our finger on the pulse of regulatory oversight, helping facilities understand the newest regulations, their implications for the Clinical Revenue Cycle , and the latest trends in audits