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Services

Ambulatory Surgery Centers

MED-REC SYSTEMS specializes in providing quality health information consulting services to free-standing and hospital-based ambulatory surgery centers. Highly qualified AHIMA credentialed health information consultants assist in the analysis and organization of the health information systems.

The health information consulting services include review of a randomly selected sampling of clinical encounters, paper-based, electronic, or a combination of both, on a predetermined basis. Detail-oriented review of the encounters from admission to discharge using data collection worksheets for documentation requirements per the Indiana State Department of Health Regulations, Medicare Conditions of Coverage as well as AAAHC, Joint Commission and HFAP standards are completed at each visit. Practical solutions to documentation problems are offered. A quality indicator study analysis is also maintained for clinical record completion on an ongoing basis to track target problem areas.

Onsite and remote CPT AND ICD-10-CM coding audits to validate supportive documentation coding practices in the clinical records is available. ICD-10-CM training is available upon request by our AHIMA-approved ICD-10-CM Trainers.

Consulting Services

  • Review Clinical Records for Compliance with State and Federal Regulations
  • Review Clinical Records for Compliance with AAAHC, JC or ACHC
  • CPT and ICD-10-CM Supportive Documentation Audits
  • ICD-10-CM Training
  • Clinical Record Policy and Procedure Review
  • Analysis and Assistance with Transition from Paper to Electronic Health Records
  • Development and Revision of Surgery Center Clinical Record Forms
  • Retention/Storage/Filing/Destruction of Records per State and Federal Regulations
  • Training of Medical Record and Coding Staff

In-Service Topics

  • Regulatory and Accreditation Documentation Requirements
  • Charting Techniques and Guidelines
  • CPT & ICD-10-CM Coding
  • Legal Aspects for Charting
  • Confidentiality and HIPAA
  • Any Other Related Topic

Temporary Medical Record Support

We can provide temporary support staff to assist with periodic health information processing needs. We offer quality service and flexibility to address your unique situation.

Services include, but are not limited to:

  • Record Completion and Analysis
  • CPT and ICD-10-CM Coding

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