NJPR Provides a Comprehensive Coding Review Program
Quality is paramount in every aspect of healthcare. Complete and accurate coding is required for optimal reimbursement, decision making and patient care.
NJPR is approved by the New Jersey Board of Medical Examiners to conduct individualized education sessions to improve physician understanding of documentation requirements to support code assignment and medical necessity and its impact on correct code assignment and subsequent billing.
The key elements of NJPR’s data quality review program are as follows:
- Assess documentation to determine if current clinical documentation practices support the ICD-10-CM/PCS code sets
- Verify ICD-10-CM/PCS, CPT and E/M for coding accuracy
- Review current diagnosis-related groups (DRGs) and ambulatory payment classifications (APCs) and subsequent recommendations that will directly impact reimbursement
- Evaluate coding practices from a compliance and reimbursement perspective
- Develop focused education based on review findings
NJPR’s coding quality review programs are designed to improve the accuracy of coded data and provide valuable information regarding a facility’s adherence to general coding and compliance guidelines and coding principals.
Resolving and Responding to Denied Claims – Hospital cases denied by payers challenging diagnoses or DRG assignment require an in-depth review of documentation and coding. Our coding expertise and experience challenging multiple payer denials provides for a comprehensive and balanced assessment and determination. NJPR prepares the written response and rebuttal for submission to the payer within the required timeframes. In addition, NJPR can provide clerical support to prepare the responses. We can readily work within the hospital platforms for tracking receipt, response and outcome.
Physician claims denied or identified as having aberrant patterns in claim submission require detailed review of E/M code assignment and supporting documentation. NJPR provides analysis by coders experienced in E/M coding and auditing. Detailed reporting allows our clients or their legal representative to respond to the denials and develop corrective action plans.
ICD-10-CM/PCS Coding and DRG Validation: Pre-Bill and Retrospective Review
NJPR’s program is designed to refine ICD-10-CM/PCS code assignment to ensure given codes are appropriate and thus result in proper reimbursement. NJPR offers both a pre-bill and retrospective review program as well as DRG appeal review.
Pre-bill program: Designed to identify and target key areas by coupling a review of codes with education; administered in real time to ensure coding accuracy prior to codes/bills being finalized
Retrospective program: Designed to meet all compliance plan requirements for external data quality reviews, improve the quality of coded data and provide valuable information regarding a hospital’s adherence to general coding and compliance guidelines and coding principles
Review and Revision of Resource Guides
NJPR provides a review of ancillary and physician office resource guides /worksheets to ensure the correct ICD-10 and CPT codes are the most current resource for the staff. NJPR will provide the necessary detail to ensure coder understanding of code description, navigating code books and documentation requirements. NJPR can customize the review based on staff experience, payer denials and specialty.
Resolving and Responding to Denied Claims
Many times, cases brought to us have been denied by payers or have been identified as having aberrant patterns in claim submission, and require an 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 clients to develop corrective action. NJPR representatives have served as expert witnesses in arbitration hearings. Typically, our services in this area are on a fee-for-service, non-contingency basis.
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. As denials can reach back to prior years, our coders have extensive experience and knowledge in Evaluation and Management, (E/M), ICD-9 and ICD-10, CPT coding guidelines in place at the time services were provided. NJPR reviews the corresponding claim to ensure the codes submitted were supported by the 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.
NJPR works closely with physicians and their legal counsel to ensure compliance with required monitoring, audits and educational requirements.
For more information on how NJPR’s data quality review services can improve your accuracy, contact us today.