CDI Review & Coding
Documentation that supports the code, and codes that match the record
Clinical documentation integrity review checks that every diagnosis and service on a claim is supported by the note behind it. We review outpatient charts before and after billing, validate documentation against the codes, run compliant provider queries and audit coding accuracy. The aim is accuracy, not inflation.
- Pre-bill and retrospective review
- ICD-10-CM, HCC, E/M, CPT II, modifiers
- Compliant query workflows
Who it's for
Built for the organizations that carry this work
Practices and medical groups
Primary care and specialty practices that want an independent check on documentation and coding before claims go out, or after a payer review.
Risk-bearing groups and ACOs
Organizations whose revenue rests on risk scores, where every submitted HCC needs support in the record.
FQHCs and health systems
Coding and compliance teams that need a structured audit program, error-rate reporting and provider feedback.
Practices facing denials or audits
Teams seeing denial patterns, coding variance between providers, or a RADV or payer record request.
What we do
What you receive
- 01
Clinical documentation integrity reviews
Pre-bill (concurrent) and retrospective outpatient chart review, sampled by provider, service line or risk tier.
- 02
Documentation-to-code validation
ICD-10-CM specificity, HCC support with MEAT-style evidence (Monitor, Evaluate, Assess, Treat), CPT and E/M level, CPT II quality codes and modifiers, each checked against what the note actually shows.
- 03
Compliant provider query workflows
Non-leading queries that present the clinical indicators and let the provider decide, with documented responses and turnaround tracking.
- 04
Coding accuracy audits
Error-rate reporting by provider and by error type, both under- and over-coding, with individual provider feedback.
- 05
Education
Provider and coder education on the documentation gaps the audits find, built from your own charts rather than generic slides.
- 06
RADV readiness and denial root cause
RADV-style sampling and a record-retrieval process, plus root-cause analysis of denials and coding variance so fixes happen at the source.
How it works
How an engagement runs
- 1
Scope and sample
Agree the review type (pre-bill or retrospective), code sets in scope, sample size and the payer rules that apply.
- 2
Review
Certified review of each sampled encounter: documentation against every code, with findings recorded by element.
- 3
Query
Where documentation is unclear or incomplete, a compliant query goes to the provider; the provider decides.
- 4
Report
Accuracy and error rates by provider and error type, with each finding traceable to the chart.
- 5
Educate
Focused feedback and education for providers and coders on the patterns found.
- 6
Re-audit
A follow-up sample to confirm the change held, and a recurring audit calendar.
Program facts
Standards we review against
What documentation-to-code validation checks
ICD-10-CM
- What the record has to show
- The most specific code the documentation supports: type, stage, laterality, acuity and linked complications, with no code beyond what the provider documented.
HCC diagnoses
- What the record has to show
- Each condition monitored, evaluated, assessed or treated at a face-to-face encounter in the year, by an acceptable provider type, in a signed note.
CPT and E/M level
- What the record has to show
- The level supported by medical decision making or total time as documented, under the current E/M guidelines.
CPT II quality codes
- What the record has to show
- The reported result (for example a blood pressure or A1c range) present in the note for that date of service.
Modifiers
- What the record has to show
- A documented, separately identifiable service or the circumstance the modifier describes (for example modifier 25 with a same-day E/M).
Documentation gaps we see most often
Condition on the problem list with no assessment
- Why it fails review
- A listed diagnosis is not evidence it was addressed at the visit.
"History of" for an active, treated condition
- Why it fails review
- Under-codes the condition and loses the HCC, for example AFib still on anticoagulation.
Unspecified code when specificity is documented elsewhere
- Why it fails review
- E11.9 or N18.9 when the note names a complication or stage.
BMI code without the provider's obesity diagnosis
- Why it fails review
- BMI alone never supports the obesity code.
Copy-forward problem lists and unsigned notes
- Why it fails review
- Among the first things a RADV reviewer rejects.
FAQs
Common questions
What is the difference between pre-bill and retrospective review?
Pre-bill (concurrent) review checks documentation and codes before the claim is submitted, so corrections happen before payment. Retrospective review samples claims already paid, to measure accuracy, find patterns and correct the source.
Will this increase our risk scores or revenue?
We do not promise either. The review makes codes match the record. Where documentation supports a more specific code, it is captured; where it does not, the code is removed. Many practices find both.
What makes a provider query compliant?
It presents the clinical indicators from the record, offers clinically reasonable options including 'other' or 'unable to determine', and does not lead the provider toward a diagnosis or mention payment. The provider's answer is documented in the record.
How does this help with RADV audits?
CMS now audits every MA contract every year, and auditors request records from the practice. Reviewing HCCs against RADV support standards before submission, and having a record-retrieval process ready, lowers the share of diagnoses that fail review.
Do you submit or change our claims?
No. You remain the billing party. We report findings and recommended corrections; your coding and billing team makes changes under your compliance policy.
Ready to simplify the complex?
Let’s look at your program together.
A consultation is a working conversation about your panel, payers and EHR, and whether this service fits. Please do not send patient information.
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