Medicare Coding/MS-DRG Audits

If the diagnoses and procedures aren’t coded properly, you are not capturing an accurate picture of your patient’s severity-of-illness and leaving yourself unrewarded in terms of reimbursement. That’s where MMP can help.

Our certified coding professionals perform a review of coded data and medical record documentation to identify and assess areas of risk related to compliance and specific targeted areas driven by the Recovery Auditors (RA), Medicare Administrative Contractors (MAC), Case Mix Index (CMI), Office of Inspector General (OIG) work plan, and/or any trends that we have identified.

Return on Investment (ROI):

MMP will also provide historical data, based on MMP’s actual professional experiences, regarding each DRG that is identified as being “at risk”. For example, Pneumonia (DRG group 193-194-195) for FY 2012:

  • Coding Opportunities resulted in a 27% change in overall records reviewed
  • Coding Risk Mitigation resulted in a 5% change in overall records reviewed

Combined, MMP has identified a total of 32% of Coding Opportunities and Risk Mitigation for Pneumonia cases

As part of the audits performed by MMP, the following services are provided:

Top 10 MS-DRG Analysis

Certified coding professionals perform a confidential and in-depth analysis of a Customer’s Top 10 MS-DRGs. This analysis is primarily designed to identify opportunities to:

  • Identify the top 10 MS-DRGs for a fiscal year
  • Compare the geometric mean length of stay (GMLOS) to the Customer’s actual length of stay (LOS)
  • Compare national MS-DRG relative weights from the prior fiscal year to the current fiscal year identifying actual realized reimbursement for the Customer (if Customer provides their own specific base/blended rate; otherwise, MMP will utilize Medicare’s national average base/blended rate)
  • Identify potential “at risk” MS-DRGs targeted by the MAC, RA, OIG, CERT and other payer investigations

The data for this analysis will be provided by RealTime™ Medical Data (RTMD), MMP’s sister-company, and will be based on total paid Medicare claims only.

Focused Medical Record Review/MS-DRG Validation

Accuracy for:

  • ICD-9-CM diagnosis & procedure codes
  • Present on Admission (POA) status indicator
  • Sequencing
  • Potential complication/co-morbidity opportunities
  • Identify potential documentation and/or query opportunities
  • Discharge disposition status code
  • DRG assignment
  • Reimbursement
  • Providing statistical breakdown of coding deficiencies (coder specific if name is provided)
  • Identifying Official Coding Guidelines and Coding Clinic resources applicable to the findings and recommendations
  • Develop focused education

Our audits enable our clients to:

  • Identify appropriate reimbursement adjusting under or over coding
  • Identify potential complication/co-morbidity opportunities
  • Provide a statistical breakdown of overall coding errors (up and down), as well as coding errors by individual coder (if name is provided)
  • Provide a statistical breakdown of overall physicians (if name is provided)
  • Identify official coding guidelines applicable to the findings and develop focused educational efforts
  • Identify potential query and documentation opportunities
  • Identify physician legibility issues
  • Educate medical staff

Individual Patient Worksheets with preliminary findings are provided to the Client for review, as well as a conference call to review findings, prior to a final report being submitted to the Client.

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