Compliance and Coding Audit Services

BESLER Consulting offers a comprehensive selection of audit and assessment 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.
Our services include:

 

Physician Practice Revenue Integrity Services

BESLER Consulting provides pre-acquisition and existing practice revenue integrity services. Our clients find our services invaluable in the practice acquisition due diligence process and for ensuring that existing practices are compliant in their billing and revenue cycle operations. Effectively managing the physician revenue cycle and revenue integrity requires expertise specific to physicians vs. hospital revenue cycle. Our approach is to meet with practice leadership to gain an understanding of past practices, current operations and situations that may be unique to an organization. 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.

 

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.

 

Charge Description Master Reviews

A periodic on-site Charge Description Master (CDM) review performed by an independent third party is essential to maintaining an accurate, current and compliant CDM. CPT and HCPCS codes are updated, deleted and modified every calendar year. The BESLER Consulting CDM 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 CDM compliance which ultimately impacts the effectiveness of your Revenue Cycle and the ability to submit clean claims.

 

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.

 

Observation Services

With a dramatic increase in short stay medical necessity denials, many hospitals have impulsively implemented Observation Services. In most cases the result has been a double-digit increase in the percentage of patients placed in observation status. The hiring of third party Physician Advisory Services to support level of care determination is another fix Hospitals have put in place to address short stay medical necessity denials. In most case the result has been a reduction in denials, but an escalating service cost and dependence. BESLER Consulting believes that the most effective means to address these issues is to implement a well-defined internal Observation program. The goals of this program include review of medical necessity and placement of the patient in the appropriate level and setting of care ; Bridge the Observation Services Clinical/Financial gap; Provide the tools, training and education to determine the appropriate level of care at the time of admission; Ensure that Observation services are provided as efficiently and effectively as possible. Our clinical/financial team includes a Physician Advisor, Nursing specialist and the BESLER Consulting team of operational and revenue cycle experts.

 

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.