A structured coding and billing audit validation program will assist your facility in correcting flaws that may reduce revenue, as well as keep you prepared for the escalating levels of external scrutiny imposed by government regulators.
As an external, unbiased, third-party, Healthcare Cost Solutions (HCS) provides various audit services by credentialed HIM professionals experienced in coding and reimbursement compliance. Our on-site and remote validation audit processes assist your organization in identifying and correcting occurrences of “overcoding” and “undercoding.” An Exit Conference educational session is conducted with the coding staff at the conclusion of every audit. CEUs are awarded to all staff in attendance. 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 with trends and patterns identified that can be used for internal communication and administrative discussion.

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DRG Audit

Through a review of inpatient records, a DRG audit assesses the accuracy and validity of ICD-10-CM diagnosis and procedure codes and appropriate MS-DRG and/or 3M™ All Patient Refined DRG (APR DRG) Classification System assignment.  At the discretion of the client, discharge status assignments and present-on-admission indicators are also verified.

HIM APC Audit

As in the case of the Full APC audit, an HIM APC audit consists of reviewing outpatient cases for CPT and ICD-10-CM coding accuracy and appropriate APC assignment limited to the coding performed by the HIM department. The audit may include a review of the UB and the patient’s bill but does not include review of CPT codes resulting from the posting of charges via the facility’s CDM.

ICD-10-CM / PCS Clinical Documentation Review

Review of provider’s documentation to identify areas of documentation likely to impact specificity and reimbursement which could result in increased queries and delayed billing.

Medical Necessity Reviews

The Medical Necessity review provides an experienced nurse auditor to evaluate the level of care provided based on the severity of illness, intensity of service, and physician orders for inpatient admissions.

HCC Audit

The HCC audit examines managed care charts for incomplete coding and/or over coding in the Hierarchical Condition Categories. CMS-HHC, CMS-PACE, and HHS-HCC models are reviewed.

OIG High Profile Cases

Each year the Office of the Inspector General (OIG) Work Plan should be reviewed by your organization’s Compliance Committee, Revenue Cycle, HIM, and senior leadership. Keep in mind that the OIG work plan is setting forth the compliance and enforcement projects and priorities that they intend to pursue in the coming year. Focus audits should be conducted in the targeted areas.

Long Term Acute Care Audit

The Long Term Acute Care audit assists the LTAC facilities with their compliance efforts by monitoring government standards related to clinical documentation and coding assignment.

Full APC Audit

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.

Professional Fee Coding Audit

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.

RAC and Third-Party Claim Review and Appeals

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.

PACT Accuracy Audit

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.

Itemized Charge Detail Audit

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.

Interventional Radiology 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.