Physician Documentation Review (PDR) Program

 Physician Documentation Review Program

This Program was developed in 1992, to establish a systematic process for reviewing provider’s documentation of services to be billed, to assess the accuracy, quality and compliance with UCDHS billing policies and other applicable billing rules and regulations in the Ambulatory Care Clinics at the University of California, Davis, Health System (UCDHS).   In 2008, this program was blended with the UCDHS EMR Provider Training to integrate EMR functionality with the coding and documentation requirements.
This Program is responsible for performing sample documentation and/or charge entry reviews as part of an ongoing quality improvement process for Ambulatory Care Administration providers.  After the documentation is reviewed, feedback is given to the providers and on-site education is offered to review quality and EMR optimization opportunities.
The timing and frequency for Physician Documentation and/or Charge Entry Reviews may vary depending on Ambulatory or Compliance directions per the UCDHS Policy 1921, Professional Fee Billing Compliance Plan however, at a minimum will assess:

1. 10 encounters annually for providers performing their own coding
2. 10 encounters biennially for providers with abstracting services (Coders)