Posts Tagged ‘coding compliance’
What to Expect in Due Diligence Audits & How to Find the Right Auditing Vendor
The healthcare industry sees hundreds of facility acquisitions and mergers every year. A critical part of mergers and acquisitions is the due diligence process, which provides a complete financial and performance picture of a healthcare organization to ensure it is a sound investment.
Read MoreCoding Compliance Audit Statistics: What to Do With Them?
Year by year, organizations rely more and more on their data analytics. In this article you will be provided with: An overview of key statistics to include in your coding compliance audits, a Questionnaire to determine if you need a coding compliance audit program…
Read MoreCMS PEPPER Report to Include Total Knee Arthroplasty (TKA)
The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a quarterly electronic data report that contains a hospital’s claims data statistics for Medicare Severity Diagnosis-Related Groups (MS-DRGs). CMS has approved the addition of a new target area to the quarterly PEPPER report related to inpatient total knee arthroplasty (TKA).
Read MoreThe Importance of Specificity in Documentation and Coding HCCs
As a follow-up to our previous articles on the subject of Risk Adjustment and HCCs, we now review some scenarios of HCC chronic conditions and the importance of specificity in documentation and coding. Accurate and complete documentation of chronic condition diagnoses by clinicians is an essential component of the risk adjustment and the HCC process. It is also imperative that the documentation of a disease/condition be as specific as possible. Specificity can make a difference in the patient’s treatment plans, as well as accurate code assignments, which then leads to appropriate HCC assignment and payment.
Read MoreCoding Audits: How Identifying Issues Sooner Rather than Later Saves Money for the Hospital/Facility
The establishment of a coding compliance program remains a significant effort by the Office of the Inspector General (OIG) in its attempt to engage the healthcare community in combating fraud and abuse. The OIG developed a Compliance Resource Portal with materials and guidelines for healthcare professionals. A fundamental element to an effective compliance program is conducting internal monitoring and auditing. Coding audits have the added value of ensuring you are running an efficient and profitable, not to mention minimized liability, operation. Earlier detection of any potential coding issues will pay off financially and will reduce risks for additional external audits.
Read MoreCase Study: Coding Quality Improvement Plan for Healthcare Facility Acquisition Process of a Large Physician Group
Healthcare facilities and independent practices face unique challenges when merging or being acquired. This case study provides a thorough analysis on the unique challenges a medical facility faces when merging with independent practices, as well as solutions for a successful facility acquisition process.
Read MoreIncrease Revenue & Lower Compliance Risk With These 6 E/M Tips
Selecting the right E/M code can be tricky – and sometimes, costly – business. On the one hand, the coder does not want to choose a diagnosis that’s too high, which could potentially incur audits or claims denials. But, if the coder selects a code that’s too low, there’s a chance of losing revenue for his or her organization. According to Medical Economics, “payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM] – or time spent counseling and coordinating care) for each E/M level” (2020).
Read MoreTop 8 Changes Medicare Payment Systems Will See In 2020
The Centers for Medicare & Medicaid Services (CMS) is implementing 8 major changes this year to the Medicare payment systems, according to Becker’s ASC Review (2019). A majority of these changes come from the organization’s 2020 Medicare Hospital Outpatient Prospective Payment System and ASC Payment System Final Rule (CMS, 2019). Other changes were due to the finalization of the CY 2020 Medicare Physician Fee Schedule Final Rule (CMS, 2019).
Read MoreBackground & Overview of ICD-11 Before Implementation in 2022
The World Health Organization released the 11th edition of the International Classification of Diseases (ICD). This release was presented at the World Health Assembly on May 25, 2019 for adoption by member states, and will come into effect on January 1, 2022. However, note that it is still unknown when ICD-11 will be ready for implementation in the United States.
Read MoreMedicare Advantage Insurers Use Reviews to Get Higher Payments
An investigation by the Office of Inspector General (OIG) revealed Medicare Advantage insurers might be overstating patients’ diagnoses without the proper documentation to receive larger payments. Based on the 2016 Medicare Advantage encounter data analyzed by the OIG, insurers were able to get an extra $6.7 billion in payments in 2017.
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