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Department of Audit Support and Compliance Services

 

THE NEED

With the countless challenges that impact healthcare providers today, it has never been more important to properly document your clinical services to satisfy reporting requirements for the procedures, supplies and medical services that you provide.

HOW WE HELP

The Association for Rural Health Professional Coding (ARHPC) performs thousands of documentation and coding reviews related to the Rural Health industry. The reviews we perform encompass Evaluation and Management (E&M) services and all other applicable aspects of coding and billing for providers in Rural Health Clinics (RHCs), Community Health (FQHCs), Critical Access Hospitals (CAHs) and other locations including those providers in group or solo practice. Audits can be performed using a variety of methods (e.g., prospective or retrospective) and we carefully tailor each of our contractual agreements to meet the individual needs of the client.

Whether you are trying to assess and mitigate the risk your providers may be currently exposing your facility or if you are trying to respond to an insurance company’s demand for refund or documentation requests, let us navigate you through the often misunderstood coding and documentation landscape.

WHO WE ARE

ARHPC offers a number of audit strategies based on the individual client’s situational needs. John F. Burns is a dual-certified coder and auditor (CPC, CEMC, CPC-I and CPMA) who brings more than 20 years of diverse experience to the table and is well suited to handle reviews of all sizes and nearly most medical specialties including rural health, primary care, anesthesia, psychiatry and mental health, orthopedics, cardiology, OB/GYN, dermatology, among others.

WHAT WE DO

The ‘typical’ auditing review process for each provider we review includes:

  • An encounter selection process (10-20 encounters typically selected for each provider)
    • We suggest an array of services (e.g., new patients, established patients, etc.)

  • Documentation for each case will carefully consider:
    • That the appropriate category and level of E&M service was selected,
    • Medical necessity, the chief complaint and/or nature of presenting problem,
    • History (subjective)
    • Examination (objective)
      • We will perform the reviews of the physical examination using CMS and CPT guidance where client policy or MAC policy is not available
    • Medical decision making (MDM)
      • Even for categories of E&M requiring that only 2 of 3 “key components” (e.g., established patient outpatient visits 99212-99215) are required, reviews will be performed assuming that Medical Decision Making must be 1 of the required documentation elements
    • The accuracy of CPT/HCPCS II modifiers (e.g., -CG, -25, etc), where applicable, and
    • The accuracy and specificity of ICD-10-CM codes.

  • An executive summary and audit template is completed for each provider reviewed demonstrating coding error rates and applicable findings.

  • Each provider is provided 30-60 minutes of specified education following the review if he/she chooses to focused on mitigating future risk and implementing corrective measures to ‘right’ any identified areas of shortcoming
    • Disclaimers:
    1. CMS mandates require that any identified instances of inappropriate coding/billing that are identified (regardless of the way in which it is identified), must have financial restoration to the CMS. Failure to do so may be interpreted by CMS as a false claim.
    2. ARHPC does not offer legal advice to our clients. We base all opinions and/or advice on the interpretations of CMS, AMA and regional MAC guidance. Our goal is to help the provider/organization code, bill and document in fashions beneficial to optimizing coding and minimizing the risks associated with audit exposure and post-payment review.

WHAT WE NEED FROM YOU

For most engagements, we each sign a HIPPA-compliant Business Associate Agreement in order to give us access to your Protected Health Information under the “Treatment, Payment, and Health Care Operations” disclosure section of HIPAA. All information is handled via HIPPA-compliant secure file transfers that are password-protected and access-controlled.

We welcome working through your legal team in order to keep the information covered under attorney-client privilege!

  1. We send you a spreadsheet where you will enter the patient information (by number or name) and which CPT/ICD-10-CM codes were reported.
  2. You provide the completed spreadsheet above to us along with:
    1. Copies of all clinical documentation specific to the date of service in question.
    2. If possible, a scan of the claim or listing of the codes submitted on the CMS1450/1500 forms.
  3. We perform our review of the documentation to determine if the level of service is supported, is over-coded, or is under-coded according to CMS guidelines.
  4. We return the spreadsheet to you along with the level of history, exam, and medical decision making in the clinical note along with comments on anything needing clarification or compliance tips.
  5. We return an Executive Summary on each provider’s audit outlining key issues and areas that need improvement along with references to the source documents for educational purposes.
  6. (Optional) – We provide a one-on-one 30-minute phone webinar with one of our consultants for each provider to go over their results. If preferred, this session can be to more than one provider at a time.
  7. (Optional) – We can come to your clinic to present the findings and to provide continuing education to your whole team, including clinical providers, coders, billers, EHR staff, management, and revenue cycle staff.

WHERE TO GO FROM HERE

For a quote or more information, contact John Burns, Vice President, Audit Support and Compliance Services (ARHPC). He can be reached at John.Burns@RuralHealthCoding.com or 518-796-7227.

 

© ARHPC | All Rights Reserved

ARHPC is a division of Universal Medical & Compliance, LLC
P.O. Box 1405 Tucker, GA 30085

Education :: Certification :: Audit Support

 

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