Outpatient Medicare Coding Review

Outpatient medical record review can tell a hospital a lot about its risk of non-compliance, potential loss of reimbursement, and potential overpayment – each an important factor for hospitals providing outpatient services. Plus, these reviews can be used to validate the hospital is doing a good job.

Using the HIQUP report, MMP identifies specific claims for review, usually targeting those with potential discrepancies or concerns. Hospitals also have the option to select their own records for review.

MMP’s outpatient review team uses information from the 835 Medicare remittances and patients’ medical records to perform these reviews. Depending on the client’s preference, the review can be either in-depth - looking at all services billed, or focused – looking only at specific codes or services.

Some of the specific areas that are audited include:

  • Medical necessity, claim denials, and line item rejections
  • HCPCS/CPT-4 code assignment
  • HCPCS/CPT-4 codes and revenue code linkage
  • Appropriateness of modifier application
  • Units of service
  • Value and condition codes
  • "Date spans"
  • Non-covered codes
  • Billing manipulations
  • Edit validity
  • Physician legibility
  • Appropriateness of bill type

Additional features of this service include:

  • Review and investigation of "medical necessity issues" directly related to actual documentation of physicians' order versus ICD-9 diagnosis codes submitted
  • Review and investigation of "billing" edit capabilities to compare final UB04 submitted for review against billing information reflected on the 835 remittance form
  • Identification of issues related to the CDM, e.g. hard coded versus dynamic coding assignments
  • Review of coding competency by coding abstract
  • Admission status

Outpatient UB reviews that we perform, include the following key performance indicators (KPI):

  • Patient Status
    Reviewed on each record to determine the appropriateness of the patient status based on documentation in the medical record, including the order, i.e., inpatient, outpatient, observation; areas of concern related to billing of observation services are also identified.
  • CPT/HCPCS Code Accuracy
    Includes verification of CPT/HCPCS codes reflected on the outpatient claim whether assigned by coding staff or hard-coded in the chargemaster, correct Coding initiative edits, omitted codes, and appropriateness of charges based on applicable Medicare billing guidelines.
  • Documentation
    A review of the medical record to see if proper documentation is present support all services billed, including physician’s orders that are signed by the physician.
  • Denials Management
    Targets claims that were denied in their entirety, and claims with line item denials related to medical necessity or issues with modifiers.
  • Compliance/RAC
    Encompasses outpatient services currently known to be included in the RAC audits, services billed with incorrect units of service or incorrect dates of service, and other compliance related issues not addressed above.

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