Coding Review & Education

Protection Against Submitting False or Inaccurate Claims

Our reviews by RN Auditors and/or Coding Specialists identify potential problems with billing documentation and coding accuracy.  Due to the complexity of current charging systems, documentation and billing errors are common and have a wide variation from facility to facility.

Accurate, Compliant, and Appropriate Payments

The primary objective of our service is to ensure that services are ordered by a physician and provided to the patient according to hospital protocol, documented in the medical record, and billed correctly.

Inpatient Coding and DRG Reviews

Our program consists of verifying the accuracy of the codes assigned and validating that the documentation supports them.  We feel that education is an extremely important aspect of this review and provide both coder and physician education as requested.  The use of actual data from your site makes the education more focused and valuable to your staff. We support our suggestions with Official Coding Guidelines and Coding Clinic back up.

Outpatient Coding and APC Reviews

This program can be all inclusive of areas in your facility that are impacted by APC payments. Your facility criteria are adhered to in the determination of levels of care in Clinics and Emergency Department reviews. Correct usage of Modifiers is reviewed to ensure that proper reimbursement is recovered by your facility and Medical Necessity is reviewed to be sure payments will not be denied. As with all coding reviews that we perform, education is a part of the review. CPT and ICD-9 coding suggestions are supported by CPT Assistant and Coding Clinic, as well as Official Coding Guidelines.

Physician Billing Reviews

We review billing and supporting documentation submitted on behalf of Physicians to determine if the correct Evaluation and Management Procedure Codes are submitted on their services performed. Documentation to support and protect the Physician billing is of the utmost importance to any Physician Practice Plan, Physician Group of Individual billing for their services. This review includes proper diagnosis code assignment for Medical Necessity of services, E&M or procedure coding and Modifier application that will ensure that the practices stay compliant with their billing practices. Education is a large part of this process for the Physician and Coding Staff and is enhanced by using actual data extracted from their reviews.

Avoid Medicare Outlier Payment Problems

We have a progressive compliance strategy to ensure that billing for Medicare payments for outliers and services is appropriate. Our strategy is designed to ensure the greatest level of scrutiny to help identify potential problems. We will perform a line item review of patient records to determine if care is reasonable and necessary. We address documentation issues and charging in the light of official Federal, State, and Institutional guidelines and OIG alerts.

Here is how our service benefits your facility:

• Accurate Coding Assignments
• Appropriate Payments
• Validation of Outlier Payments
• Management and Statistical Report
• Customized Training for Physicians, Coders, and Compliance Staff