Understanding the Concurrent Review: A Proactive Approach to Coding and Compliance

Understanding the Concurrent Review: A Proactive Approach to Coding and Compliance

A concurrent coding review is one of the key strategies health systems can implement to ensure coding integrity and reduce the number of claim denials. This approach provides real-time oversight of coding and documentation before claims are submitted, improving accuracy, compliance, and revenue integrity.

What is a Concurrent Review?

A concurrent review is the process of evaluating clinical documentation and coding accuracy while the patient is still receiving care or before claims are officially submitted. Unlike retrospective audits conducted after discharge, concurrent coding reviews help identify discrepancies and documentation gaps early, ensuring that claims are as accurate as possible before they are sent to payers.

This process requires coders to have remote access to patient charts and clinical documentation within the electronic medical record (EMR) system. By conducting real-time analysis of diagnosis codes, coders can verify that the documentation supports the codes before claim submission, reducing the risk of denied claims and reimbursement delays.

Concurrent Review vs. Retrospective Review vs. Prospective Review

Each type of review has distinct characteristics and purposes. Here are some brief differences between concurrent, retrospective, and prospective reviews:

Concurrent Review

• Occurs before claim submission but during or immediately after a patient’s hospital stay.
• Ensures that documentation and coding are accurate before the claim is finalized.
• Helps prevent denials by catching errors early.
• Requires ongoing communication between CDI teams, coders, and providers.

Retrospective Review

• Takes place after the claim has been submitted and often after reimbursement has been issued.
• Identifies patterns of errors and areas for provider education.
• Can lead to claim resubmissions or appeals but may delay reimbursement corrections.
• Typically used for compliance monitoring and performance improvement.

Prospective Review

• Occurs before services are provided or before a procedure is performed.
• Focuses on determining medical necessity and verifying prior authorizations.
• Ensures that planned procedures meet payer requirements to avoid claim denials.
• More commonly used in pre-authorization processes than in coding accuracy.

The Value of a Concurrent Review

Implementing a concurrent review process offers several advantages for health systems, including:

Improved Coding Accuracy

Concurrent coding ensures that medical records are reviewed and coded correctly before claim submission, reducing the need for corrections and rework. Accurate coding minimizes claim denials and accelerates the revenue cycle.

Enhanced Compliance

With real-time audits, organizations can proactively identify compliance issues, ensuring documentation aligns with regulatory requirements such as Medicare guidelines, payer policies, and official coding rules. This approach reduces the risk of audits, fines, and penalties.

Reimbursement Optimization

A concurrent review helps healthcare organizations optimize reimbursement and minimize revenue leakage by capturing all reportable diagnoses and procedures upfront. Timely and accurate documentation ensures that claims reflect the full scope of services provided.

Faster Claim Processing

A concurrent review helps prevent coding and documentation errors from delaying claims. When claims are accurate upon initial submission, payers can process reimbursements faster, improving cash flow.

Reduced Administrative Burden

By catching errors early, a concurrent review minimizes the need for costly rework, appeals, and retrospective audits. This efficiency frees up resources and allows staff to focus on higher-value tasks.

The Process of Concurrent Auditing

Concurrent audits can take different forms depending on the health system’s needs, but the general process includes:

1. Chart Review: Coders and auditors assess active patient records, ensuring that diagnoses and procedures are accurately documented and coded.
2. Clinical Documentation Integrity (CDI) Review: CDI specialists work alongside providers to clarify ambiguous or incomplete documentation in real time.
3. Compliance and Coding Accuracy Checks: Auditors verify adherence to payer-specific guidelines, official coding rules, and regulatory requirements.
4. Immediate Feedback: Providers and coding teams receive timely feedback, allowing them to make necessary adjustments before claims are finalized.
5. Claim Submission: Once coding is validated and documentation gaps are addressed, claims are submitted with a higher degree of accuracy.

Challenges in Implementing Concurrent Review

Despite its advantages, a concurrent review does present a few challenges:

• Increased Workload: Conducting real-time audits requires dedicated resources and staff.
• Workflow Integration: Organizations must ensure that concurrent review processes fit seamlessly into their existing documentation and billing workflows.
• Balancing Speed and Accuracy: While concurrent audits enhance accuracy, they can also add time to the claim submission process if not managed efficiently.

Managing a concurrent coding review process can be a challenge, but that’s where an experienced partner like YES HIM Consulting makes all the difference. With dedicated professionals who specialize in concurrent audits, we ensure coding integrity without overburdening internal staff. Our team works seamlessly within existing documentation and billing workflows, offering immediate feedback to coding teams and providers. By leveraging our industry expertise and best practices, YES helps organizations reduce claim denials, optimize reimbursements, and maintain compliance – allowing healthcare leaders to focus on delivering quality patient care.

Choosing the Right Partner for Your Concurrent Coding Review

The concurrent review is a proactive strategy that enhances coding accuracy and improves financial outcomes. By addressing documentation gaps in real time, health systems can reduce claim denials, improve reimbursement rates, and ensure that clinical documentation reflects the full scope of patient care.

To learn more about enhancing coding integrity and compliance, don’t miss exploring the various types of audits beyond just concurrent reviews.

If your organization needs to conduct any type of review, fill out the form below to speak to our auditing experts.