Coding Compliance and Data Quality Audits

A structured coding and billing audit validation program will assist your facility in correcting flaws that may reduce revenue, while at the same time keep you prepared for the escalating levels of external scrutiny imposed by government regulators.

As an external, non-biased, third-party, Healthcare Cost Solutions (HCS) provides various audit services by credentialed coding professionals experienced in coding and reimbursement compliance. Our on-site or remote validation audit process assists your organization in identifying and correcting occurrences of "over " and "undercoding." Recommendations for coding changes are supported by authoritative, official coding and billing references. Potential documentation issues are identified and a comprehensive documentation of findings is provided in a detailed summary report.

• DRG Audit
• Audit consists of a review of inpatient records assessing the accuracy and validity of ICD-9-CM diagnosis and procedures along with the corresponding DRGs. Discharge status assignment and present on admission indicators are also verified at the discretion of the client.
• Full APC Audit
  This consists of a review of outpatient surgery, clinic and/or emergency room records. ICD-9-CM diagnosis and procedures, CPT and HCPC procedure codes, along with corresponding APCs are reviewed for coding compliance. This audit includes a review of all procedures assigned on the UB-04 (patient's bill).
• Partial APC Audit
  This audit consists of a review of outpatient surgery and/or emergency room records. ICD-9-CM diagnosis and procedures, CPT and HCPC procedure codes, along with the corresponding APCs are reviewed for coding compliance. This audit does not include review of procedures assigned by the Chargemaster System. The UB-04 (patient's bill) may also be reviewed.
• RAC / MAC / MIC Reviews and Appeals
  HCS auditors are experienced in the RAC review and appeal process, having worked with the California RAC since 2006. Support is offered in the form of preparation, education, trending, case review, preparation of appeals, and tracking. (MAC and MIC reviews and appeals are also available)
• HCC Audit
  Managed care charts are audited for Hierarchical Condition Categories for incomplete coding and/or over coding.
• Intervention Radiology Audit
• Audit consists of outpatient interventional radiology records. CPT and HCPC procedure codes are reviewed for coding compliance. Review of ICD-9-CM diagnosis and UB-04 (patient's bill) may also be reviewed.
• Long Term Acute Care Audit
  Audit assists the Long Term Acute Care facilities with their compliance efforts by monitoring government standards related to clinical documentation and coding assignment.
• OIG High Profile Cases
  A target review of high profile cases is conducted, with support in the form of case reviews provided. A summarization of findings, feedback, and education for hospital staff and physicians is conducted.
• Revenue Cycle Assessments
  With financial improvement as a goal, HCS will partner with you and your staff to determine areas for revenue cyle improvement and provide services necessary to address them.
• Professional Fee Coding Audit
  This audit consists of a review of physician office/clinic or hospital based physician notes, ICD-9-CM diagnosis and CPT procedure codes for professional fee billing.
• Medical Necessity Reviews
  Review of one-day stay inpatient admissions by experienced nurse auditor, who evaluates level of care provided based on severity of illness, intensity of service, and physician orders.
• Itemized Charge Detail Audit
  Experienced nurses review the itemized bill against documentation in the medical records to verify items charged. Summary of findings are presented at the conclusion of the audit.