Inpatient and Outpatient Coding Compliance Reviews

YPRO consultants review inpatient and outpatient records for coding compliance based on guidelines established by payer policy guidelines and coding guidelines as established by Coding Clinic and CPT Assistant. These are the recognized sources of reference for coding.

PURPOSE
An Inpatient and Outpatient Coding Compliance Review will assist the facility with the following:
1. Identify if facility is accurately assigning codes
2. Identify if facility is accurately documenting supporting clinical events
3. Identify if facility is accurately selecting principal diagnosis
4. Identify if facility is accurately coding principal and secondary procedures
5. Identify if facility is accurately assigning codes to all complications and co-morbidities
6. Identify if facility is accurately utilizing modifiers
7. Identify if facility is accurately assigning DRG or APC
8. Identify coding accuracy by coder

METHODOLOGY
Inpatient records are selected for review (using a target list if the hospital chooses) to determine the DRG groups that are most likely to be coded or sequenced incorrectly. If the facility wants a specific group of DRG's to be reviewed, YPRO is willing to accommodate this request. The records are reviewed for accuracy of documentation, correct assignment of codes and sequencing for DRG assignment. The DRG on the Remittance Advice is also compared to the DRG on the attestation or UB-92 to identify possible billing discrepancies. Recommendations are made on a worksheet for changes in coding whether DRG assignment is affected or not. The average review consists of up to 200 records.

Outpatient records are selected for review based on the needs of the facility. Generally, same day surgeries are reviewed using a random sampling of the most common procedures performed. Some facilities also request a review of ER, outpatient clinics, laboratory and radiology records. It is our policy to work with the facility to meet their needs in the selection and volume of records to be reviewed. Documentation, appropriate assignment of ICD-9-CM, CPT-4 codes and modifiers are reviewed for accuracy. Any recommendations are made in the form of a worksheet detailing the change and giving supporting documentation.

The review findings are presented in the form of an oral summary report to the coding staff. The coding staff is presented with examples, references and the latest regulatory information. Your staff can obtain 1 CE unit for attending this exit summary report. The client is presented with a written report identifying the detail findings, recommendations and references. The written report, a compilation of the inpatient and outpatient findings, can be utilized in future training and to meet compliance regulatory requirements.

BENEFITS
· Improve reimbursement
· Improve regulatory compliance
· Improve coding staff quality
· Improve quality ratings/rankings
· Reduce denials
· Identifies educational opportunities

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