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Top 10 Compliance Issues 2020

Top Documentation and Coding issues to include in 2020 Compliance Plans

What’s in your 2020 compliance plan?

Make sure you are addressing these top ten documentation and coding compliance concerns.

For Hospitals

  1. Risk-based review of inpatient DRG cases, examples include:
    • RAC DRG targets
    • Clinical indicators, cases at risk for clinical denials (e.g. Sepsis, CHF, ARF, severe malnutrition, encephalopathy)
    • IP cases with only 1 MCC/CC code or HACs
    • IP short stay cases (24 – 48 hours) with complex principal diagnosis (e.g. Sepsis, AKI, ARF)
    • Expired patients with risk of mortality (ROM) level 1, 2 or 3
    • DRGs 981 – 983 surgical procedure unrelated to principal diagnosis
    • Complex surgical procedures such as spinal fusions, open heart surgeries and/or intestinal excision and resection procedures
    • Discharge Disposition accuracy for DRGs subject to being paid under the Medicare Post-Acute Care Transfer Rule
  2. Short stays and inpatient readmissions (ensure compliance with admission criteria and 2-Midnight rule)
  3. Clinical indicators, specific to the patient and episode of care, must support queries. Review physician queries to assure query language is compliant and not leading.
  4. Infusion and injection coding (including J codes with correct units charged, drug wasting and JW modifier)
  5. Interventional radiology and interventional cardiology procedure coding and billing
  6. Outpatient Dialysis claims to ensure compliance with Medicare requirements
  7. Facet joint injections (CPT 64490 – 64495) inclusive of fluoroscopy CT guidance and contrast injection
  8. Outpatient Cardiac and Pulmonary Rehabilitation meet medical necessity and comply with certain documentation requirements.
  9. NICU (ensure clinical documentation meets medical necessity for NICU level of service)
  10. Data mining to identify trends/outliers (e.g. high utilization of certain DRG, unspecified diagnosis codes or procedure codes, identify and follow up on trends in claim denials)

For Physician Practices

  1. Risk-based review of evaluation and management codes (E/M):
    • Review providers with higher than 10% of visits in level 4 and 5
    • Level 4 and 5 visits with only one diagnosis code
    • Review providers with outliers on E/M bell curve analysis
    • Conduct highly productive provider analysis (review visits per day outlier)
    • Appropriate use of prolonged and critical care services codes
    • Appropriate documentation of time for time-based E/M codes
  2. Appropriate use of Modifiers:
    • High-risk modifiers: 25, 57, 59 (including XE, XP, XS, XU)
    • Other modifiers to focus on: 24, 58, 62, 63, 76, 78, 80, AS
  3. Incident to services (appropriate reporting of NPP services and split-shared services)
  4. Teaching physician and supervising physician services
  5. Coding and reporting co-morbidities for coverage of routine foot care (meeting specificity in the LCD, use of modifiers Q7, Q8, Q9)
  6. Wound care (especially debridement services 1104x, 97597)
  7. Due diligence audits for new providers
  8. Copy/Paste documentation (ensure documentation is unique for the visit and presenting complaints)
  9. Chart review for documentation of active treatment and specificity of chronic conditions to support HCCS
  10. Data mining to identify trends/outliers (e.g. conduct top billed procedure analysis, identify and follow up on trends in claim denials)