Coding Audits and Denial Management

New research claims the typical health system risks $4.9 million each year due to claims denials. Preventative action is critical and audits are a practical approach. Whether to validate code assignment, check DRG selection or review coding compliance, H.I.M. ON CALL’s expert auditors deliver an unbiased view of quality and accuracy. Each audit is tailored to meet the client’s specific needs and expectations.

5 Steps to Fewer Denials

1.

Kick-off Meeting: Onsite event to determine the most cost-efficient, impactful audit scope and methodology.

2.

Target Selection: Identify specific focus for each audit or review including high-risk diagnosis and DRGs, principal diagnosis, principal procedure, and specific CC or MCC conditions.

3.

Validation Review: Complete validation of all diagnosis code assignments, procedure codes, sequencing and code specificity to ensure compliance with correct coding rules and latest guidelines. Validation (retrospective or concurrent) of all DRG (MS/APR) assignments is also provided.

4.

Opportunity Improvement Report: Define all documentation improvement and coder education opportunities including a comprehensive report of all findings and recommendations.

5.

Customized Education: Education and training program options are also available to address specific coder knowledge gaps and clinical documentation insufficiencies identified throughout the project.

Learn how our credentialed auditors pinpoint your areas of revenue vulnerability and identify opportunities for financial and coding performance improvement.

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After the Audit: Focus on ICD-10 Specificity and Financial Impact

ICD-10 elevated the need for specific code assignment. Any use of unspecified codes will most probably result in claims denials and recovery contractor reviews.

Upon completion of H.I.M. ON CALL’s audit and validation of a satisfactory rate for DRG assessments, our expert team takes a closer look at any unspecified diagnosis or procedure codes uncovered during the review to:

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Define unspecified code rate

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Uncover possible causes and opportunities for improvement

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Report missed query opportunities

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Determine financial impact

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Recommend targeted education for coders, CDI specialists and physicians

Audit Program Checklist

Here is specific data that our auditors identify and use to summarize clients’ findings:

Client DeliverableInpatient Audit Outpatient Audit
HOC Reviewer IDXX
Coder IDXX
Number of records reviewedXX
Number of changesXX
DRG ChangesX
APC ChangesX
APC accuracy rateX
E&M Level changesX
Modifier changesX
Patient Status changesX
Severity of illness changesX
DRG accuracy rateX
Principal diagnosis accuracy rateX
Overall coding accuracy rateXX
CC/MCC accuracy rateX
Financial impactXX
Reason for changeXX
Summary of errors by ICD-10 CM chapterX
Summary of errors by ICD-10 PCS chapterX
Summary of errors by CPT sectionX
Rationale for changes with specific coding guideline referencesXX

Flexible single, monthly, quarterly or annual audit programs are available.

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