Transcript Medicaid Recovery Contractor Initiative Updates Documentation

Documentation Strategies to Reduce Financial
Exposure
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS,
PCS, CCDS, C-CDIS
Objectives
 Receive an update on the NC Medicaid Recovery Audit
Contractor program
 Understand the chosen “basics” of the NC RAC
program
 Learn likely areas of NC RAC focus
 Appreciate clinical documentation tips and strategies
to reduce RAC financial exposure
Medicaid RAC Provisions
 Section 6411 Affordable Care Act, Expansion of the
RAC Program, required States to establish programs to
contract with RACs by December 31,2010
 Delay in implementation by April 2011
 Implementation of program when Final Rule
published
State Medicaid RAC Plan
 Section 1902 (a)(42)(B)(i) SSA-Title XIX of the SSA, NC
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
Medicaid established RAC program
State will make RAC payments contingency
Contingency payments will not exceed highest rate paid
under Medicare RAC
$30 fee paid per underpayment identified
Efforts of the Medicaid RAC(s) will be coordinated with
other contractors or entities performing audits of entities
receiving payments under the State plan or wavier in the
State, and/or State and Federal law enforcement entities
and the CMS Medicaid Integrity Program
Traditional Preparation
 RAC Committee formation
 Software application
 Adherence to record submission and appeal timelines
 Staffing to conduct appeals
 Financial reserves
The “Skeleton in the Closet”
8
The “$64,000 Question”
 Clinical documentation
 Quality
 Effectiveness
 Consistency
 Accuracy
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Documentation Processes
 Hospital Admission
 Emergency Room
 Direct Admit
 Hospital Outpatient
 Scheduled elective outpatient procedures
 Labs and radiology
 Emergency Room
 Charge Capture
 Chargemaster
 Ancillary staff “soft coding”
Hospital Documentation
ER
Discharge
Summary
H&P
Medical
Record
Consult
Ancillary
Staff
Progress
Notes
Medical Necessity
 Section 1862 (a)(1)(a) Social Security Act Title XVII
 “No payment can be made that is not reasonable and
necessary for the diagnosis or treatment of illness or
injury or to improve functioning of a malformed body
member”
 Medical Necessity
 “Responsibility of the Physician”
 Medicare and other 3rd party payer guidelines
 Screening criteria
Commercial Screening Criteria
 “CMS considers use screening criteria as only one tool
that should be utilized by contractors “
 Medical record must indicate that inpatient hospital
care was medically necessary, reasonable, and
appropriate for the diagnosis and condition of the
beneficiary at anytime during the stay(Chapter 6,
Section 6.5.2, of the Medicare Program Integrity
Manual)
 Reviewer applies clinical judgment
Additional Criteria
 Admission criteria;
 Invasive procedure criteria;
 CMS coverage guidelines;
 Published CMS criteria;
 DRG validation guidelines;
 Coding guidelines;
 Other screens, criteria, and guidelines (e.g., practice
guidelines that are well excepted by the medical
community)
Signs & Symptoms
 Beneficiary must demonstrate signs and symptoms to
warrant need for medical care and must receive
services of such intensity that they can be furnished
safely and effectively only on an inpatient basis
 Consider any pre-existing medical problems or
extenuating circumstances that make admission of the
beneficiary medically necessary
 Inpatient care rather than outpatient is required only
if the beneficiary’s medical condition, safety, or health
would be significantly and directly threatened if care
was provided in a less intensive setting
Physician’s Responsibility
 The decision to admit a patient is a complex medical
judgment which can be made only after the physician
has considered a number of factors, including the
patient's medical history and current medical needs,
the types of facilities available to inpatients and to
outpatients, the hospital's by-laws and admissions
policies, and the relative appropriateness of treatment
in each setting. (Medicare Benefit Policy Manual
Chapter 1 Section 10)
Factors to be Considered
 Factors to be considered when making the decision to
admit include such things as:
 The severity of the signs and symptoms exhibited by the
patient;
 The medical predictability of something adverse happening
to the patient;
 The need for diagnostic studies that appropriately are
outpatient services (i.e., their performance does not
ordinarily require the patient to remain at the hospital for 24
hours or more) to assist in assessing whether the patient
should be admitted; and
 The availability of diagnostic procedures at the time when
and at the location where the patient presents.
Lack of Focus
 Medical record documentation
 Severity signs and symptoms
 Portrayal of patient acuity
 Risk of morbidity and mortality
 Predictability of adverse outcomes
 Provisional diagnoses
Typical Case
 Mrs. Jones, a 78 year old woman presented to the
Emergency Room in acute respiratory distress, with
difficulty breathing that started about two hours prior
to presentation to the ER. She has known COPD and
continues to smoke, now requiring supplemental
oxygen 2 liters round the clock.
 PMH: COPD, CHF, lung cancer status post lobectomy
and chemo, hypertension.
 Vital signs: HR 120, RR 34, Temperature 99 F, oxygen
sats 85%, appears in no respiratory distress, A & O x 3
Medical Necessity
 Physician lack of appreciation and understanding
 “This patient does not meet medical necessity criteria”
 “Please change the patient status to outpatient”
 “Please document for medical necessity”
Severity
Clinical Impression
 Acute COPD
 Hypoxemia
 Morbidly obese
 Tobacco addiction
 Plan-admit and treat
Clinical Impression
 Acute exacerbation of COPD
 Acute on chronic respiratory
failure
 Morbid obesity
 Tobacco addiction-continues to
smoke
 Plan- will need to admit patient
and improve patient’s
oxygenation, currently she is on
a 100% non-rebreather in the
hopes of avoiding the vent. Last
admission she was on the vent
and had to be discharged to
LTAC to wean her off the vent
Severity of Illness
 SOI
 Extent of organ system derangement or physiologic
decompensation for a patient
 Gives medical classification:




Minor
Moderate
Major
Extreme
 Serves as basis for evaluating hospital resource use
 Assigned SOI based upon specific diagnoses and
procedures performed
Severity of Illness
 Clinical Screening criteria
 Dyspnea and >= one:



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
Respiratory rate >= 24/min
Stridor
Heart rate >=100/min
Change in mental status
Sputum smear/culture (+) for bacteria/fungi/protozoa
Medical
Necessity
• Clinical Documentation
• Severity of Illness
• Risk of Mortality
Hospital
• Physician Judgment
Physician • Medical Decision Making/Medical Necessity
Disconnect
Clinical
indicators
Physician
Documentation
Severity
of
Illness
Different Perspective
Clinical Documentation
 Medical Necessity

Hospital/Physician admission and continued stay
 Severity of Illness


Screening criteria
Physician clinical judgment, medical decision making,
admission & discharge
 Revenue Cycle

Denials avoidance and appeals
 Strategy to minimize denials/financial exposure
Clinical Documentation Today
 Required to record pertinent facts, findings, and
observations about an individual’s health history
including past and present illnesses, examinations,
tests, treatments, and outcomes
 Chronologically, documents the care of the patient and
is an important element contributing to high quality
care
The “Great Facilitator
 Medical record facilitates:
 the ability of the physician and other healthcare
professionals to evaluate and plan the patient's
immediate treatment, and to monitor his/her healthcare
over time;
 communication and continuity of care among
physicians and other healthcare professionals involved
in the patient's care;
The “Great Facilitator
 accurate and timely claims review and payment;
 appropriate utilization review and quality of care
evaluations; and
 collection of data that may be useful for research and
education
The Great Blender
Reducing that “Hassle Factor”
 An appropriately documented medical record can
reduce many of the "hassles"
 Associated with claims processing and may serve as a
legal document to verify the care provided, if necessary.
 Associated with retrospective queries from Health
Information Management coding
“Clinical Documentation-Why the
Fuss”
 Providing services consistent with standards of
medical care, evidenced based medicine, and
insurance coverage
 Site of service
 Medical necessity and appropriateness of the diagnostic
and/or therapeutic services provided; and/or
 Services provided have been accurately reported
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Documentation Purposes
 Outlines and highlights patient’s clinical presentation
 History of Present Illness and context
 Constellation of signs and symptoms
 Recording of physical findings
 Assimilating historical data and physical findings in
into clinical context
 Formulation of Working Hypotheses
Documentation Purposes
 Justification for diagnostic workup
 Development and documentation of clinical diagnoses
 Development and implementation of care plan
 Adherence to best practice, evidence based medicine
 Quality measurement
Documentation Purposes
 Support of outcome studies
 Risk of mortality and morbidity, severity of illness
 Risk adjusted readmissions
 Promotes continuity of care
 Measurement of efficiency/value
 Represents clinical judgment and medical decision-making
in support of medical necessity depiction for hospital and
physician
 Provisions of clinical data for research and education
 Supports and justifies resource consumption and research
Measurement of Efficiency
 Efficiency
 “Providing and ordering a level of services that is
sufficient to meet a patient’s health care needs but is not
excessive, given the patient’s health status”
Documentation Deficiencies
 Result of Documentation Deficiencies
 Appearance of unnecessary use of resources
 Appearance of inefficient practice of medicine
 Non-support of medical necessity
 Reporting of nonspecific diagnoses/symptoms versus
definitive diagnoses
 Inaccurate reporting of patient outcomes
 Poor, inadequate communication between providers
 Increased risk of hospital readmissions
Principles of Medical Record
Documentation
 Medical should be complete and legible
 Documentation of each patient encounter should
include:
 Reason for the encounter and relevant history,
physical examination findings, and prior
diagnostic test results;
Principles of Medical Record
Documentation
 The documentation of each patient encounter should include:
 assessment, clinical impression, or diagnosis;
 plan for care; and
 date and legible identity of the observer
 Documentation should support intensity of patient evaluation and/or
treatment, including thought processes and the complexity of medical
decision-making as it relates to the patient’s chief complaint for the
encounter
Principles of Medical Record
Documentation
 Past and present diagnoses should be accessible to the
treating and/or consulting physician.
 Appropriate health risk factors should be identified.
Principles of Documentation
 The documentation should support the
intensity of the patient evaluation and/or the
treatment, including thought processes and the
complexity of medical decision-making as it
relates to the patient's chief complaint for the
encounter.
Principles of Documentation
 The patient's progress, including response to
treatment, change in treatment, change in diagnosis,
and patient non-compliance should be documented
Nature of Presenting Problem
 Ensure the nature of the patient’s presentation
corresponds to CPT’s contributory factors of the
nature of the presenting problem and/or patient’s
status descriptions for the code reported.
Nature of Presenting Problem
 For instance:
 99231 – “Usually the patient is stable, recovering or
improving.”
 99232 – “Usually the patient is responding inadequately
to therapy or has developed a minor complication.”
 99233 – “Usually the patient is unstable or has developed
a significant complication or a significant new problem.”
Importance of Proper and
Accurate Documentation
 Services billed to the Medicare program are the sole
responsibility of the Medicare provider.
 Documentation needs to be unique, specific, and
should accurately reflect the services you are
billing.
Importance of Proper and
Accurate Documentation
 Documentation not only must reflect necessity and
the services provided but also must be consistent
among the providers involved in an episode of care.
 Medicare payment for services may be denied if the
supporting documentation is not thorough.
Clinical Case Study
 H & P Assessment HD #3
 Right Lower Lobe Infiltrate- start IV Zosyn and
Levaquin
 Pulmonary edema- diurese
 H & H decreased- watch closely and transfuse if
necessary
 Cardiac arrhythmia- continue Rythmol and Coumadin
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Clinical Case Study Cont.
 H & P Assessment HD #3
 Right Lower Lobe Infiltrate- start IV Zosyn and
Levaquin
 Pulmonary edema- diurese
 H & H decreased- watch closely and transfuse if
necessary
 Cardiac arrhythmia- continue Rythmol and Coumadin
New & Improved
 H & P Assessment HD #3
 Aspiration pneumonia-continue IV Zosyn and Levaquin,
patient’s respiratory status improving but still somewhat
short of breath, chest X-ray still shows some consolidation,
slowly improving, may need a few days more of IV antibiotics
 Acute on chronic systolic CHF- diuresing nicely, will consider
step down therapy to PO tomorrow
 Chronic blood loss anemia due to slowly bleeding AV
malformation- H & H decreased- watch closely and transfuse
if necessary. Will have to transfuse judiciously if necessary
given the patient’s precarious CHF with tendency to fluid
overload
Congruence
Clinical
Doc
ACO
Efficienc
y
Med
Necessity
Quality
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Widespread Probe Review
 Trailblazer widespread review MS-DRG 690- Urinary
Tract Infection
 Post-payment sample of 100 claims
 Paid claims error rate 38.27 percent
 Records reviewed for:
 Verification of Medicare coverage for billed services
 Determination of medical necessity
 Determination of appropriateness of care setting
 Validation of the MS-DRG
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Lack of Medical Necessity
 Examples lack of medical necessity denials:
 Physicians writing admission orders for acute
inpatient care for a patient documented as stable,
receiving oral medications, without fever, and with
normal laboratory values
 Admission orders are written for acute inpatient
care for a condition or complication not
substantiated by supporting documentation
from members of the interdisciplinary team
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Lack of Medical Necessity
 The documentation of admission assessment was
insufficient
 The documentation did not support an inpatient level
of care
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Key Elements of Medical Record
Documentation
 “Reasonable and Medically Necessary” and
“Supporting Documentation” are key elements of
medical record documentation
 Interdisciplinary team documentation of assessment,
intervention, and outcomes provides a picture of
patient’s clinical condition and response to
treatment
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The Sum of the Components
 Each component is useful in determining
“reasonable and medically necessary” services are
provided and billed to the contractor for
reimbursement
 Objective clinical documentation solidifies
admission/continued stay medical necessity
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RAC Related Denials
 Lack of consistency in entry in medical record
 Assessments, treatment plans, physician orders, nursing
notes, medication and treatment records, etc., and other
facility documents such as admission and discharge
data, pharmacy records, etc.
 Provider’s failed to adequately document significant
changes in the patient’s condition or care issues that in
some instances impacted the review determination
57
Added Value
 Ancillary Provider Documentation supports and
facilitates provider patient status decisions:
 The severity of signs and symptoms exhibited by
the patient;
 The medical predictability of something adverse
happening to the patient ;
 The need for diagnostic studies;
 The availability of diagnostic procedures at the
time when and at the location where the patient
presents
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A “Few” More Words
 During medical review, the medical reviewer considers
any pre-existing medical problems or extenuating
circumstances that make the admission of the
beneficiary medically necessary.
 Inpatient care rather than outpatient care is required
only if the beneficiary's medical condition, safety or
health would be significantly and directly threatened
if care was provided in a less intensive setting.
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The “Last Word”
 Inpatient care rather than outpatient care is required
only if the beneficiary's medical condition, safety or
health would be significantly and directly threatened
if care was provided in a less intensive setting.
 Objective account of assessment, interventions, and
outcomes, response to treatment.
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Medical Necessity & Diagnosis
 For a service to be considered medically necessary, it
must be all of the following:
 Appropriate in duration and frequency
 Meets but does not exceed patient’s medical needs
 Provided in accordance with accepted standards of
medical practice
 Not experimental or investigational
 Performed by qualified personnel in an appropriate
setting
61
Relevant Note
 Medicare requires the informational content (the facts
about the patient’s condition) in the medical record to
demonstrate all of the above.
 The facts, not just conclusory statements, must
demonstrate that the patient has the diagnosis
reported on the claim and that the patient’s
condition fulfills all coverage provisions of all Medicare
rules and policies.
62
Evaluation and Management
 History
 HPI
 ROS
 PFSH
 Physical Exam
 Medical Decision Making
 Number of Diagnoses and Management Options
 Amount and Complexity of Data
 Table of Risk
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Elements of E & M
 Six Major Elements
 History
 Physical Exam
 Medical Decision Making
 Counseling
 Coordination of Care
 Nature of Presenting Problem
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Key vs. Contributing Components
 Key
 History
 Physical Exam
 Medical Decision Making
 Contributing
 Nature of Presenting Problem
 Counseling
 Coordination of Care
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Documentation Requirements
 Documentation must meet following criteria
 Must be legible
 Clearly identify patient, date of service, and who
performed the service
 Accurately report all pertinent facts, findings, and
observations
 Include appropriate diagnosis for the service
provided
 Documentation must have hand written or an electronic
signature
66
What are the Payers Looking For ?
 Require reasonable documentation that services
consistent with the insurance coverage provided
 May request record to validate:
 The site of service;
 The medical necessity and appropriateness of the
diagnostic and/or therapeutic services provided;
and/or
 That services provided have been accurately
reported
67
Documentation 101
 Documentation for each patient encounter should
include:
 reason for encounter and relevant history, physical




examination findings, and prior diagnostic
test results;
assessment, clinical impression, or diagnosis;
plan for care; and
date and legible identity of the observer.
 If not documented, the rationale for ordering
diagnostic and other ancillary services should be
easily inferred
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Documentation 101
 Past and present diagnoses should be accessible to
the treating and/or consulting physician
 Appropriate health risk factors should be identified.
 The patient’s progress, response to and changes in
treatment, and revision of diagnosis should be
documented.
 The CPT and International Classification of
Diseases 9th Revision Clinical Modification (ICD-9CM) codes reported on the health insurance claim
form should be supported by the documentation in
the medical record.
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E&M
 Evaluation of patient with exchange of clinically
reasonable and necessary information
 Use of the clinical information in the
management of the patient
 Cardinal Rule of E & M coding
 No evidence of face-to-face visit→→ NO E & M
 No diagnosis documented →→ No E & M
 Specific, Accurate and Detailed
Documentation fundamental to E & M
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Basics of E & M Assignment
 Chief Complaint (CC)
 CC is a concise statement describing the symptom,
problem, condition, diagnosis, physician
recommended return, or other factor that is the
reason for the encounter.
 Every progress note must have clearly documented CC
 HPI- chronological description of the development of the
patient’s present illness from the first sign and/or
symptom or from the previous encounter to the present.
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HPI
 HPI consists of following:
 Location
 Quality
 Severity
 Duration
 Timing
 Context
 Modifying factors; and
 Associated signs and symptoms
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Take Note
 The extent of HPI, ROS and PFSH that is
obtained and documented is dependent upon
clinical judgment and the nature of the
presenting problem (Chief Complaint)
 Two levels HPI
 Brief HPI consists of 1 -3 elements
 Extended HPI consists of 4 or more elements
 H & P- strive for 4 or more elements HPI
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Role of HPI
 HPI drives:
 Extent of PFSH, ROS and physical exam performed
 Medical necessity for amount work performed and
documented
 Medical necessity for E & M assignment
 Medical necessity of an Evaluation and Management (E/M)
encounter is often visualized only when viewed through the prism of
its characteristics captured in specific History of Present Illness
(HPI) elements
Speaking of Medical Necessity
 Federal law requires that all expenses paid by
Medicare, including expenses for Evaluation and
Management services, are medically reasonable and
necessary
Medical Necessity
 Medical necessity of E/M services is generally
expressed in two ways: frequency of services and
intensity of service (CPT level).
 Medicare’s determination of medical necessity is
separate from its determination that the E/M service
was rendered as billed.
Medical Necessity
 Medicare determines medical necessity largely through the
experience and judgment of clinician coders along with the
limited tools provided in CPT and by CMS.
 At audit, Medicare will deny or downcode E/M services
that, in its judgment, exceed the patient’s documented
needs
Elements of Medical Necessity
 Medical necessity of E/M services is based on the
following attributes of the service that affected the
physician’s documented work:
 Number, acuity and severity/duration of
diagnoses/ problems addressed through history,
physical and medical decision-making.
Elements of Medical Necessity
 The context of the encounter among all other
services previously rendered for the same problem
 Complexity of documented comorbidities that clearly
influenced physician work.
 Physical scope encompassed by the problems (number
of physical systems affected by the problems).
Medical Necessity & Diagnosis
 For medical necessity, services must meet the
following:
 Appropriate in duration and frequency
 Meet but does not exceed patient’s medical needs
 Provided in accordance with accepted standard
of medical practice
 Not experimental or investigational
 Performed by qualified personnel in appropriate
setting
Qualifying Factor
 Medicare requires the informational content (the facts
about the patient’s condition) in the medical record to
demonstrate all of the above.
 The facts, not just conclusory statements, must
demonstrate that the patient has the diagnosis reported on
the claim and that the patient’s condition fulfills all
coverage provisions of all Medicare rules and policies.
Case Study “Demonstrating
Medical Necessity”
 The patient s a 61-year old male with a history of
peripheral vascular disease, who has had multiple
vascular surgeries on his right lower extremity, which
included an aortobifemoral, a right profunda to
politeal bypass, a jump graft from the common femroal
to the profunda, and a redo fem below knee popliteal
bypass. The patient presented to Ziosville
approximately 5 PM the day prior to presentation,
complaining of increased right lower extremity pain
that started below his knee. The patient does have a
significant history of claudicating, however, this pain
was at rest.
Case Study Continued
 She described it as crampy, has been increasing in
intensity since its onset, and he also reports that his
foot is cold. Currently the patient does not have any
sensation below the mid calf on his right lower
extremity and has decreased strength at his ankle, and
little to no motor function in his toes. Pain is rated at 9
out of 10 pain scale, took some Motrin this morning
with no improvement, can’t hardly walk due to the
pain.
Case Study Continued
 PMH:
 Hypertension-labile and not well controlled
 Coronary artery disease with episodes of unstable angina
relieved with nitro for the most part. CABG x 5
 Diabetes Type II uncontrolled. Patient noncompliant
with diet and medication regimen
Case Study Continued
 Assessment & Plan
 The patient is a 61-year old male with a history of peripheral
vascular disease who presents with acute on chronic limb
ischemia




Admit the patient to the peripheral vascular service under Dr Denial
We will schedule the patient for an emergent right lower extremity
thrombectomy and possible femoral to tibia bypass and possible
fasciotomies
We will need to reverse the patient’s Coumadin with fresh frozen
plasma
We will make appropriate plans for the OR including chest x-ray,
electrocardiogram, type and cross, and preoperative antibiotics
What’s the Big Deal
 Why the focus upon specific, accurate and
detailed clinical documentation?
 CERT Program
 RAC Program
 Medicare Administrative Contractor reviews
 Medicaid Integrity Contractor
 Goal to reduce Medicare paid claims error rate
by 50% by 2012
Looking Ahead
Looking Ahead
Once Again
 Clear, concise, and complete clinical documentation
essential for business success
 Physician Feedback Program
 Physician Quality Reporting System
 Pay-for-Performance
 Bundled Payments (ACE Project)
 Accountable Care Organizations
 Shared savings, Gain sharing
 ICD-10 October 2013
 Alternate Care Contracts
Healthcare Quality Reporting
 Healthgrades.com
 Whynotthebest.org
 HospitalCompare.gov
 Medicare.gov
 New feature Physician Compare allows physician
look-up
 Indicates participation in PQRS
 Indicates participation in prescribing medicines
electronically
Modifier JW
 Palmetto requires use of modifier JW
 HCPS Modifier JW-drug/biological amount
discarded/not administered to any patient
 Not used when actual drug dose administered less than
billing unit
 Billing unit 10 mg, if administer 7 mg, bill one unit w/o
JW modifier
 Coverage limited to single use vials.
 Multiple use vials not subject to payment
Modifier JW
 Drug wastage must be documented in the patient’s
medical record with date, time, amount wasted and
reason for wastage.
 Upon review, any discrepancy between amount
administered to the patient and amount billed will be
denied as non-rendered unless the wastage is clearly
and acceptably documented.
 The amount billed as “wasted” must not be
administered to another patient or billed again to
Medicare.
Documentation
Requirements
 All doses must be drawn by a licensed professional whose
scope of practice includes administration of parenteral
medications and knowledge of aseptic technique.
 All doses from a given vial should be drawn and
administered within the time period specified on the
package insert.
 Only one vial of a given concentration of the medication
should be opened and used by the administering
professional at any given time. A second vial of the same
medication must not be opened until the previous vial is
discarded.
Documentation
Requirements
 Any opened vials or filled syringes must be discarded if not
used within the specified time frame of the first puncture
of the vial. Vials must be labeled to document the time of
first entry and maintained at a temperature specified on
the package insert during non-use.
 Residual amounts of these medications (either in the vial
or syringes) must never be pooled with medication from
another vial or syringe. If a patient requires more
medication than is in a single, drawn syringe, then
medication from a separate vial should be drawn into a
separate syringe for administration
Quality Assurance
 Each facility should have in place a process-
monitoring (quality assurance) program, which
ensures compliance with these policies and
procedures. This program should include:
 Recording data on infections in treated patients.
 Unannounced practice audits involving quality
assurance staff observing performance of reuse
techniques.
Of Note
 Modifier JW not used when billing unit already
includes amount administered as well as amount
wasted.
 Example- J1275- meperidine hydrochloride, per 100 mg.
If 75 mg injected, bill one unit J1275
 J1275 100 mg includes administered amount as well as
wastage. Do not use modifier “JW”
Contact Information
 Glenn Krauss, Manager Clinical Documentation
Improvement Services, YPRO Corp
 [email protected]
 [email protected]
 603 303-3337