Auditing and Compliance Services

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We provide auditing and compliance services for both Short-Term and Long-Term Acute Care, and for a Physician’s Practice/Office, Rehabilitation and Specialty Services

Environments

  • Inpatient/Outpatient Coding Compliance (ICD-10-CM/PCS, CPT, HCPCS)
  • Validation of MS-DRGs, or APC reimbursement systems, and ICD-10-CM/PCS, CPT-4, HCPCS selections and assignments
  • Validation of the principal diagnosis, first-listed, and/or principal procedure selections and assignments
  • Validation of all secondary MCC, CC and other reportable diagnosis and/or procedure selections and assignments in addition to sequencing logic, regardless of impact to MS-DRGs, or APC calculation, to ensure overall coding quality (full code review)
  • Validation of present (POA) on admission indicator reporting
  • Validation of clinical and physician documentation improvement issues
  • Validation of query issues
  • Validation of date-of-service discrepancy issues
  • Validation of admission order, medical necessity and patient-type issues
  • Validation of discharge disposition and acute MS-DRG transfer discrepancy issues
  • Validation of operational assessment related to coding – incomplete source documentation (medical record) for accurate coding and workflow issues
  • Validation of all the above elements, which directly and potentially impact under-coded and over-coded issues; in addition to level(s) of severity

Where noted and/or requested will document anomalies with:

  • Quality assurance issues
  • Risk management issues
  • Revenue integrity issues
  • Accounts receivable/unbilled issues
  • Potential fraud and abuse issues
  • Compliance with federal, state and/or other regulatory entities
  • Research and defense of coding rationale when warranted in the execution of an appeals process

Deliverables

  • Root cause and trends
  • Final Report with findings by coder and overall facility performance: MS-DRGs/APC and overall coding accuracy, where requested; discharge disposition; patient type, POA assignment accuracy rates via Microsoft Excel and Word
  • Financial impact analysis based on findings
  • Education sessions for coding staff based on identified “teaching” opportunities, where requested; and schedule permits training on specific coding/abstracting/query logic on a case-by-case basis for options and assessments
  • Exit interview and summary with hospital leadership and administrative staff, including the CEO, CFO, controller,
  • Health Information Management Director, Coding Manager and so on

Let’s Get Started …