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EVALUATION & MANAGEMENT (PHYSICIAN E/M) REVIEW
YPRO consultants review outpatient records for appropriate E/M assignment, based on either 1995 or 1997 guidelines, whichever the clinic has adopted. ICD-9-CM & CPT-4 coding is compared to the coding guidelines as established by Coding Clinic and CPT Assistant. Appropriateness of nursing & physician documentation is carefully evaluated and compared to CMS guidelines. Modifiers and HCPCS are reviewed to ensure proper usage and payment for claims. Benchmarking statistics are used to compare physicians and/or nurse practitioners to billing patterns of similar clinic practices or specialties.
PURPOSE
A Comprehensive E/M review can assist facilities with the following:
1. Identify if documentation is appropriate for the E/M level assigned.
2. Identify if facility is accurately assigning ICD-9-CM, CPT-4 & HCPCS codes.
3. Analyze charges and track thru the billing system and ensure all claims are interfacing correctly to the 1500.
4. Assessment of overall billing cycle from submission of claim to accuracy of payment.
5. Provide expert knowledge to areas requiring Intensive Education.
METHODOLOGY
The E/M review consists of reviewing a select number of records per physician/clinician including Clinic, Consultations, Hospital Admissions, Rounds, Nursing Home, Specialty Consults, and Emergency Room E/M Visits. YPRO will validate each record for coding, documentation and compliance accuracy, as well as to verify correct assignment of E/M leveling. We review the medical record, the CMS-1500 and the remittance advice to make sure that all the information is correctly transmitted and that the reimbursement is correct. Findings are discussed with each physician, nursing, billing staff either in a group or one on one. A written summary of the review detailing the findings is submitted to the facility within two weeks of the review.
BENEFITS
· Reduce denials
· Improve reimbursement
· Improve billing procedures
· Enhance compliance adherence
· Improve quality ranking/rating
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