A Full APC audit includes a review of all procedures assigned on the UR and the patient’s bill. Reviewing observation, outpatient surgery, clinic and /or emergency room records will ensure compliance with CPT and HCPCS procedure codes, corresponding APCs, and ICD-10-CM diagnoses. The reviews typically cover codes assigned by HIM personnel or charged through the facility’s Charge Description Master (CDM) for settings including the emergency department, outpatient infusion unit and outpatient surgery. Surgical codes, evaluation and management (E&M) level assignment, drug administration charges, imaging, and separately payable pharmacy charges to calculate correct APC reimbursement are all validated in addition to validation of the ICD-10-CM diagnosis codes.
The Professional Fee Coding audit consists of a review of physician office / clinic or hospital based physician notes, ICD-10-CM diagnosis and CPT procedure codes for professional fee billing.
Claim Review and Appeals offers support in preparation, education, trending, case review, preparation of appeals, and tracking. California, as an early RAC demonstration state has been active in the review and appeal process since 2006. HCS Auditors are highly experienced and possess advance competencies in the Recovery Audit review and appeal process as well as payor denials and appeals.
The PACT Accuracy audit validates the inpatient cases that are affected by CMS’ Post-Acute Care Transfers (PACT) rule for appropriate assignment of the discharge disposition (patient status code) and identification of the potential reimbursement impact.
The Itemized Charge Detail audit includes an experienced nurse to review the itemized bill against documentation in the medical record to verify items charged. A summary of findings will be presented at the conclusion of the audit.
The Interventional Radiology audit consists of outpatient interventional radiology records where CPT and HCPCS procedure codes are reviewed for coding compliance. ICD-10-CM diagnosis codes and the UB claim form may also be examined.