Coding, Documentation and Compliance Services
BESLER Consulting offers a comprehensive selection of audit, assessment and appeal strategies to help your organization improve charge capture accuracy, ensure appropriate reimbursement and, ultimately, achieve compliant practices with regulatory requirements. Many of our clients report a significant return on investment from ensuring that claims are both compliant with Medicare guidelines and also making certain that uncollected dollars are not being left on the table.
Chart to Bill Audits
For this type of audit BESLER reviews a sample of outpatient claims from various departments to determine if the services billed are adequately documented in the medical record. In addition we verify that the charges and procedure codes (CPT, HCPCS) as well as diagnosis codes reported on the claim form are consistent with documentation in the medical record. These audits are conducted using the coding, billing, and documentation guidelines established by the Centers for Medicare and Medicaid Services (CMS) since these are typically the most stringent and generally are adopted by most payers. Medicare and other third-party billing requirements are subject to significant claim edits. These requirements and edits address claim form completion, coding detail, billing for Medicare covered services and billing accuracy.
Evaluation and Management Facility Audits
The audit consists of a thorough review of the medical records to compare existing documentation to services billed for accuracy and compliance with Medicare coding guidelines. These reviews are conducted on the facility/resource allocation and assignment of the Evaluation and Management (E/M) code selection. CMS has not defined the facility/resource criteria utilized by hospitals but instead allows hospitals to define their own criteria for the assignment of the E/M level code. Written criteria are required and BESLER can support the development of E/M level criteria for multiple outpatient departments such as the Emergency Department, Wound Care Service and Pain Management Service.
Inpatient/Outpatient Coding Assessments
BESLER will provide a thorough review of the medical records to compare existing documentation to services billed for accuracy and compliance with payer coding guidelines as well as billing requirements. As a component of our documentation review, we will assess if there are additional services that were documented that can be billed beyond the primary service. An operational assessment can be included as part of the review so that process issues are identified, recommendations to correct the root cause is identified and systematic improvements are implemented.
MS-DRG Coding Audits
This compliance audit reviews Medicare inpatient claims in order to evaluate coding accuracy per industry standard coding guidelines and the assignment of the Medicare Severity Diagnosis Related Groups (MS-DRG). Validation of the principle diagnosis selection, secondary diagnoses, principle procedure and secondary procedures with an emphasis on the complications/co-morbid conditions (CCs) and major CCs. In addition, we evaluate the accuracy of the coding for Present on Admission (POA) indicators as well as Hospital Acquired Conditions (HACs). Scorecards are utilized to trend coding errors by type and by coder in order to implement educational programs after completion of the audit.
Physician Evaluation & Management Coding/Documentation Assessmen
With the advent of Federal Program Integrity Contractors such as the RAC, MAC. MIC, ZPIC, revenue take-backs will become common place if your organization does not take preventative measures. Federal Program Integrity Contractors evaluate Hospital and Physician billing to ensure the documentation supports the level of billing. This increased scrutiny plus regulatory changes pertaining to the use of consultation codes greatly increases your organizational exposure to revenue leakage. The BESLER Physician Coding Audit Services can assist your Organization with the need to conduct Evaluation and Management audits for multiple physician practices within your healthcare system. The BESLER Consulting team of experienced auditors can efficiently and affordably provide coding, documentation and billing compliance audits; as well as education for your physician practices.
HIM Process Redesign
The Health Information Management (HIM) operation is critical to the financial viability of an organization in the revenue cycle. The BESLER approach consists of an operational assessment of the HIM functions for the organization. This includes interviews with organization management and key departmental personnel, data analysis, review of specific policies and procedures, and observations of work processes. Operational areas assessed include the Discharged Not Final Billed (DNFB) and Outpatient Exception data; accreditation and regulatory compliance; release of information processes to successfully support Federal Program Integrity medical record requests. The BESLER team brings extensive HIM as well as revenue cycle expertise to identify opportunities for improvement.
Clinical Documentation Reviews
Clinical Documentation Reviews are conducted by highly experienced nurses and clinicians that provide an organization with the expertise necessary for an analysis of the standard of care, continuity of care, DRG assignment, and more. Both the medical record and the UBs are reviewed for adherence to federal, state, and facility-specific guidelines.
A robust process can have an impact on the Centers for Medicare and Medicaid Services quality measures, present on admission, pay-for-performance, value-based purchasing, data used for decision making in healthcare reform, and other national reporting initiatives that require the specificity of clinical documentation. Improving the accuracy of clinical documentation can reduce compliance risks, minimize a healthcare facility’s vulnerability during external audits, and provide insight into legal quality of care issues.
A periodic on-site Chargemaster description review performed by an independent third party is essential to maintaining an accurate, current and compliant chargemaster. CPT and HCPCS codes are updated, deleted and modified every calendar year. The BESLER Consulting Chargemaster review solutions afford our clients a choice of services designed to meet their needs ranging from focused departmental audits to comprehensive engagements. Our staff of experts is able to assist your facility in achieving Chargemaster compliance which ultimately impacts the effectiveness of your Revenue Cycle and the ability to submit clean claims.
Medical Necessity Reviews
Because incorrect diagnosis and procedure coding may lead to overpayments and may subject a hospital to liability for the submission of false claims, hospitals should review their inpatient documentation practices. To ensure that claims are based on complete medical records and that the medical records support the levels of service on claims submitted for payment, BESLER provides a case management operational assessment. The assessment includes an assessment of case managers’ knowledge of criteria to facilitate inpatient vs. outpatient status; case managers’ proficiency with hospital designated criteria sets; assessment of case managers’ ability to prioritize cases for physician referrals; and retrospective and concurrent medical record reviews to determine accuracy of level of care determinations/medical necessity. The BESLER service identifies the root cause of issues and through the implementation of a corrective action plan provides permanent issue resolution.
Review of Short Day Stays
Due to the advent of the Recovery Audit Contractors (“RAC”) and other Federal Program Integrity provider audits focusing on Emergency Department (“ED”) visits and short day stay patients, many hospitals find themselves over or under utilizing observation services due to lack of a formalized case management and billing process. This may be resulting in a loss of observation revenue, loss of charges in the outpatient setting or loss of inpatient MS-DRG revenue. Organizations incurring the expense of both internal and external resources will benefit from the BESLER service to assess and recommend improvements to more effectively utilize internal resources and reduce the reliance on external support. The BESLER service indentifies the root cause issues and through the implementation of a corrective action plan provides permanent issue resolution.