Make sure you are addressing these top documentation and coding compliance concerns.
- Risk-based review of inpatient DRG cases, examples include:
- RAC DRG targets; PEPPER targeted DRGs
- COVID related inpatient discharges
- 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 HAC/PSI cases
- 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 infusions, 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
- Short stays, inpatient readmissions, and three day Skilled Nursing Facility Qualifying Admissions (ensure compliance with admission criteria and 2-Midnight rule)
- 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.
- Infusion and injection coding (including J codes with correct units charged, drug wasting, and JW modifier)
- Interventional radiology and interventional cardiology procedure coding and billing
- Outpatient Dialysis claims to ensure compliance with Medicare requirements
- Facet joint injections (CPT 64490-64495) inclusive of fluoroscopy CT guidance and contrast injection
- Outpatient Cardiac and Pulmonary Rehabilitation meet medical necessity and comply with certain documentation requirements
- NICU (ensure clinical documentation meets medical necessity for NICU level of service)
- Data mining to identify trends/outliers (e.g. high utilization of certain DRGs, unspecified diagnosis codes or procedure codes, identify and follow up on trends in claim denials)