Typically referral records, physician documentation, OASIS information, and any supporting clinical or medication records. The more complete the documentation, the more accurate and consistent the coding can be.
FAQs
FAQs
Frequently Asked Questions
- What documentation do you need to begin ICD-10 coding?
- Do you code from the OASIS assessment?
OASIS information is reviewed alongside the clinical record to support diagnosis selection and check for consistency, but coding is based on the documentation as a whole rather than the OASIS alone.
- Who reviews the coding?
Coding is completed under physician-led (MD) oversight. Diagnoses are reviewed for documentation support, sequencing, and alignment with the home health plan of care before the record is returned to your team.
- Do you sign or finalize the 485?
No. We prepare the fill-in draft and review it; final review, approval, dating, and signature always remain with the agency’s authorized licensed clinician.
- What do you need to prepare a 485 draft?
Typically the OASIS, physician orders, referral and clinical documentation, and any supporting records. More complete documentation supports a more consistent draft.
- How is the 485 reviewed for accuracy?
Under MD-led oversight, the draft is checked against the OASIS and clinical record for diagnosis support, order consistency, and documentation alignment.
- Do you complete or correct the OASIS for us?
No. We provide review findings and correction recommendations; the licensed clinician makes any final changes and approves the assessment.
- What records do you need for an OASIS review?
The OASIS assessment plus supporting clinical and referral documentation. More complete records support a more thorough review.
- What kind of issues do you flag in an OASIS review?
Inconsistencies between the OASIS and the clinical record, unclear or missing documentation, and items that may need clinician follow-up.
- Do you make corrections to our records during an audit?
No. We provide QA findings and correction recommendations; the licensed clinician and agency make any final corrections.
- What records do you audit?
Referral records, physician documentation, OASIS, medication lists, and other supporting clinical records.
- How are audit findings delivered?
As clear QA findings with correction recommendations your team can act on before finalizing the chart.
- How do we get started?
Request a free consultation through our contact page or call (818) 836-1515. We will walk through your agency’s needs, case volume, and workflow, then set up a secure way to exchange documentation. Please do not send patient information through the contact form.
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