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Codebusters provides medical coding and auditing services for a wide variety of outpatient settings. We work with professionals that have experience in facility based outpatient observation and surgery coding, as well as clinic based outpatient coders. Each coder or auditor that we work with must show experience coding in the client’s setting type and pass an exam specific to the client’s facility. Exams can be custom tailored to ensure the candidate has the specific knowledge to do the job. We fully understand the coding requirements for observation and surgery encounters contain many compliance challenges. Codebusters can assist providers in ensuring complete documentation, capturing correct information in the chargemaster, reviewing code assignment, and examining medical necessity compliance. Our coders provide documented feedback, where appropriate, in order to assist the client in full revenue capture. |
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Workforce Support Certified medical coders can be deployed onsite to the facility or offsite through remote access to the facility. Hospitals should consider performing coding reviews prior to billing, if practical. This kind of continuous auditing can identify patterns of problems with documentation or poor coding immediately. Otherwise quarterly or annual reviews should be performed on a retrospective basis. |
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Coding and billing for observation services are a common source of compliance concerns. Patients are put on an observation status to monitor their health and determine if it is necessary to admit them as inpatients, thereby reducing costs of care. The professional and facility components of observation coding are paid based on a specific set of rules. In order for the facility to receive reimbursement for observation services, the patient must be either directly admitted to observation, or come from the ED or clinic with a level 5 visit, and meet certain procedural requirements and time thresholds. Correct physician and practitioner documentation is critical for reimbursement. All procedures must be documented, including ones provided through the ED or clinic. Facilities must also make sure they follow proper procedures to ensure patients are properly screened before being put on observation status (medically necessary). Care management plans must be developed for admitting to observation, retaining in observation, and discharging from observation to acute care, home, or other services levels. Observation services indicate a patient’s status rather than a place of service. Observation can take place anywhere in a hospital, most commonly in the ER, dedicated observation area, or on an acute care unit. |
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The OIG has long made mis-classification of short stay inpatients who instead should have been admitted to observation a major point of investigation, as well as the use of Condition 44 on the technical component claim form. Codebusters auditors can evaluate the care management paths and patient screening protocols to ensure correct admittance to observation status, as well as provide training to practitioners on proper methods to document observation stays. |
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Codebusters coders ensure all procedures have a corresponding diagnosis that adheres to medically necessary payer and provider guidelines. Appropriate assignment of modifiers should also be reviewed as it affects APC assignment and thus reimbursement. APCs should be reviewed to validate appropriate transmission of HCPCS codes to the grouper and the claim form. If the record shows that services were provided but not charged, then the department responsible should receive training or processes be revised. Our professionals understand the intricacies of global surgery package rules so that providers can stay in compliance with this very complex set of guidelines. |
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