Improve coding accuracy and ensure proper reimbursement

Data quality is at the source of almost every aspect of professional healthcare. In fact, complete and accurate data are vital for optimal reimbursement, decision making and patient care.

NJPR offers a comprehensive coding data review program, including detailed spreadsheets and summaries of findings, that is designed to improve coding accuracy and ensure proper reimbursement.

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 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

Coding/Documentation Data Quality

NJPR’s coding/documentation data quality programs are designed to improve the quality of coded data and provide valuable information regarding a facility’s adherence to general coding and compliance guidelines and coding principles. The programs provide information that will also assist with organizational and operational decision making.

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

DRG appeal: Designed to assist a facility with responding to commercial and Medicare denials based on code assignment/DRG changes via thorough chart review and rebuttal based on coding guidelines

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 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 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.

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.