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Coding Quality Review

ICD-10 Gap Analysis

NJPR’s Gap Analysis program offers a comprehensive program designed to assist facilities with their transition and implementation to ICD-10-CM/PCS. Accurate and thorough coded data has always provided valuable information for organizational and operational decision making. ICD-10-CM/PCS offers organizations higher quality data which will ultimately result in improved abilities to measure quality and increased abilities to refine reimbursement. Early preparation and adequate education for the implementation of ICD-10-CM/PCS is paramount.

NJPR’s program includes these key elements:

  • Assess documentation to determine if current clinical documentation practices support the ICD-10-CM/PCS code sets
  • Verify ICD-9-CM for coding accuracy
  • Review current DRGs and APCs and subsequent recommendations that will directly impact reimbursement
  • Evaluate coding practices from a compliance and reimbursement perspective; and
  • Develop focused education based on review findings

Review and Revision of Superbills
NJPR provides a review of clinic and physician office superbills to ensure all diagnoses and procedures are assigned the appropriate ICD-10-CM/PCS code. NJPR meets with the interested parties on an individual basis to evaluate what diagnoses and procedures are pertinent to their specialty or performs a general review of the superbills and provide codes for the most common diagnosis and procedures (if applicable) for that specialty. NJPR will review the diagnoses and procedures and provide a crosswalk of codes from ICD-9-CM to ICD-10-CM/PCS. Each party will receive a revised ICD-10-CM/PCS superbill.

Physician Documentation Review and E/M and CPT Coding Analysis
NJPR has reviewed thousands of patient encounters to assess adherence to documentation and compliance guidelines and standards for Evaluation and Management (E/M), ICD-9-CM and CPT-4 coding principles. In addition to review of the medical record, NJPR will review corresponding super bills to determine if codes submitted were supported by documentation within the medical record. A review of insurance denials to determine if there is a trend in the type of denials received may be appropriate. NJPR will evaluate templated information in the electronic health record to ensure the individual patient detail is captured.

Many times, cases brought to us have been denied by payers or have been identified as having aberrant patterns in claim submission and require in depth review of documentation and coding. Our coding expertise coupled with our experience in utilization review and evaluation of medical necessity offers a comprehensive and balanced assessment and determination. Detailed reporting allows our client to develop corrective action. NJPR has served as expert witness in arbitration hearings. Typically our services are on a fee for service, non contingency basis.

NJPR is approved by the New Jersey Board of Medical Examiners to conduct review and education sessions to improve physician understanding of E/M documentation requirements and guidelines to support code assignment, and medical necessity.

NJPR works closely with physicians and their legal counsel to ensure compliance with required monitoring, audits and educational requirements.