All Consulting Services focus heavily upon the codes for the  International Classification of Diseases- 9th Clinical Modification  (ICD-9-CM), Physician’s Current Procedural Terminology  (CPT), and/or Level II of the Healthcare Common Procedure Coding System (HCPCS).

• are designed to verify that the clinical documentation in the health record supports the ICD-9-CM, CPT, HCPCS Level II and modifiers reported by the healthcare provider. These audits can be performed on cases that have or have not been submitted for payment to the third-party payer. For retrospective coding audits, the UB-04 and CMS-1500 claim forms are also reviewed to verify the coding and billing data submitted for payment, such as revenue codes and units of service.

Billing Audits

• are designed to verify that the clinical documentation in the health record supports the charges reflected on both the itemized patient bills and the UB-04 or CMS-1500 claim forms. These audits also focus on the healthcare provider’s compliance with the third-party payer’s guidelines for: insurance verification, coverage, claims processing/billing/adjudication.

Chargemaster Reviews

• are designed to identify the following in the healthcare provider’s chargemaster(s): deleted, invalid, non-covered, non-reportable CPT/HCPCS codes; inconsistent CPT/HCPCS codes and line item descriptions; inappropriate revenue code assignments for CPT/ HCPCS codes; and opportunities for additional line items based on the provider’s service mix. Key staff will also be interviewed to assist our team in identifying the precise nature of supplies, tests, services, and procedures performed at the facility.

Operational Assessments

• are designed to identify operational activities that need to be implemented, enhanced, or re-engineered for the healthcare provider to successfully comply with the various third-party payer guidelines and requirements. A Management Action Plan will also be prepared based on the client’s responses to “Operations uestionnaires,” client feedback during Strategic Planning Sessions, and our team’s review of: departmental policies and procedures, departmental meeting minutes, performance improvement initiatives, information system User’s Manuals, health record forms, patient clinical and reimbursement data.

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Fort Washington, MD   20744
(V) 301-292-8027
(FAX) 301-292-8244
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