Coding News from NEPHO
The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) recommend that health care providers routinely enlist independent parties to audit coding practices. Chart audits are a way to obtain feedback regarding your coding program and help in measuring quality.
Although the goals may generally be the same, coding audits can differ in several ways, including methodology type, accuracy definitions, and cost.
Coding Audit Methodologies
Coding audits can be retrospective, which is a review of submitted claims, or prospective, an analysis of pre-billed claims. They can also be random, targeted, or a mix of both, and a code-for-code or full-record analysis.
Establishing a regular external coding audit will have a high return on investment (ROI), helping you maintain the best coding practices for the well-being of your practice. Most importantly, it will help identify potential coding and documentation problems and reduce risk of lost revenue from denials.
Coding Audits Help To:
- Determine if day to day operating procedures are compliant with current regulations
- Prevent non-compliance issues from occurring
- Reduce potential for over or underpayments
- Reduce risk of improper documentation
- Minimize risk of fraud
- Ensure compliance with Medicaid and Medicare standards
- Address areas of coding education opportunity
NEPHO Coding Audit Findings:
In an ongoing effort to ensure accuracy and compliant coding NEPHO performed an outpatient service chart audit review on three NEPHO physician practices. The findings addressed areas of opportunity for provider education. A trend identified included missing preventative screening ICD-10 diagnosis codes that were released October 1, 2018. The initial review was done in January 2019 and follow-up review was completed in February 2019. The follow-up coding review found that all 3 practices had improved with capture of the new ICD-10 diagnosis codes for screening encounters.
Z00-Z99 Factors influencing health status and contact with health services
- 81 Encounter for examination and observation of victim following forced sexual exploitation (ruled out)
- 82 Encounter for examination and observation of victim following forced labor exploitation (ruled out)
- 89 Encounter for examination and observation for other specified reasons (ruled out)
- 30 Encounter for screening examination for mental health and behavioral disorders, unspecified
- 31 Encounter for screening for depression
- 32 Encounter for screening for maternal depression
- 39 Encounter for screening examination for other mental health and behavioral disorders
- 40 Encounter for screening for unspecified developmental delays
- 41 Encounter for autism screening
- 42 Encounter for screening for global developmental delays (milestones)
- 49 Encounter for screening for other developmental delays
- 821 Contact with and (suspected) exposure to Zika virus
- 83 Immunization not carried out due to unavailability of vaccine
- 430 Family history of elevated lipoprotein(a)
- 438 Family history of other disorder of lipoprotein metabolism and other lipedemia
Creating a Proactive Approach to Coding Denials
Recent data show a rise in claim denials from Medicare/Medicaid and commercial payers. Almost 80% of denials are now from commercial payers. Though denial prevention is the ultimate goal, creating a strategy for management of denials and appeals is necessary for practice success.
Implementing a Proactive Appeal Strategy
- Establish a team approach:
Hold regular meetings with practice staff to review reports, discuss issues, track trends, and monitor outcomes.
- Work closely with the Contracting and Provider Relations:
Providers need to understand payment policies and contract language and exercise their right to the appeal process.
- Never assume the denial is correct:
Investigate the rationale for the denial and make sure coding resources are up to date. Verify references and note discrepancies in your appeal. Have an under-standing of the appeal process and payer filing limits.
- Provide periodic training for practice staff:
The following links are resources available to help keep practice staff trained:
Best -practices when claims are denied
Patient advocate resources – insurance-denials-appleals
Additional resources are available to help manage denials and appeals on all payer provider portals.
Areas to focus on to help reduce coding denials that impact revenue:
- Heightened Focus on Clinical Validation: Even when a provider’s documentation clearly states a diagnosis, it will be challenged if the payer determines there are insufficient clinical indicators or discussion points to support the diagnosis. Medical necessity needs to support the reason for visit and diagnosis coded.
Example: A procedure can be denied for not meeting medical necessity. An x-ray for the ankle would not be taken when the patient is having chest pain as that does not meet medical necessity. An x-ray of the ankle would be taken for “ankle pain” or “ankle swelling”.
- Data collection and reporting: Reports identify dollars at risk, dollars recovered, problem payers, denial trends, and missed coding opportunity to increase revenue. A benefit of reviewing data is the ability to identify the root causes and frequency of payer denials while providing an educational opportunity to help in reduction of denials.
Example: A practice receives denials for a specific CPT code. Review denial detail and follow-up with payer on specifics; NCCI edit, incorrect CPT billed, documentation issue supporting medical necessity. Always understand the reason for denial and appeal if there is supporting reason.
Example: Create a monthly report that captures services denied. Study data pulled and identify potential trends, understand the denial reason, and review dollar impact of these denials. Consult coding experts to ensure accuracy of the denial.
Please contact Shawn Bromley, Director of Operations and Contracting NEPHO, if you would like to discuss ways to implement a best practice approach to working coding denials and appeals. Shawn.firstname.lastname@example.org or 978-236-1704.