Scrutiny of coding compliance in the growing ambulatory surgical center (ASC) market has increased in recent years from both Medicare and private payers. This will only increase as the Centers for Medicare and Medicaid Services (CMS) moves towards value-based care.
In December 2018, a Pennsylvania for-profit hospital and health system, and its CEO agreed to pay a total of $12.5 million to settle allegations they submitted false claims to Medicare and other federal health care programs for orthopedic surgeries. The settlement resolves allegations that top executives exploited a loophole – AKA modifier 59 – that allowed them to double bill federal healthcare payers for surgeries and ignored coding consultants who advised them that they were improperly billing.
Top 5 ProFee diagnosis changes found in recent HIA reviews: 1. I10 – Essential (Primary) Hypertension; 2. E11.9 – Type 2 Diabetes Mellitus Without Complications; 3. K29.60 – Other Gastritis Without Bleeding; 4. R13.19 – Other Dysphagia; 5. I25.10 – Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris.
In 2003, the Centers for Medicare and Medicaid Services (CMS) implemented Risk Adjustment Factors (RAF) and Hierarchical Condition Category (HCC) coding to identify individuals with serious and/or chronic illnesses and assign them a risk factor score that is based on a combination of demographic information and reported diagnoses.
The ICD-10-CM/PCS code changes – effective October 1, 2018 to September 31, 2019 – could be the culprit. Comparatively speaking, there are far less changes this year than in years past. The release includes: 279 new codes, 51 deleted codes,143 revised codes. But don’t let the smaller amount of changes fool you…
In reviewing hundreds of contracts, the OIG found that insurers overturned 75% of their own denials upon appeal—approximately 216,000 denials each year. However, while the odds of winning an appeal are seemingly good, many providers simply don’t have the time or the internal staff and infrastructure needed to engage in the process.
Many organizations routinely perform internal audits as part of a compliance plan. Internal auditors have an insider’s view of the work flow of the organization. Unfortunately, they are auditing their coworkers, friends or employers.
So, you know you need a coding review – where do you start? Defining your goal should always be step one, but that’s not always cut and dry. The answer varies based on the objectives of your review.