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Chart Reviews - WIN! WIN!

In today's climate of decreased reimbursement and tighter compliance regulations a chart review can help identify possible loss of revenue and possible red flags that could send someone else in and cost the facility or practice a lot of money.  Missing one CPT code alone can add up to thousands of dollars for a facility or practice.  The complex world of multiple coding rules, federally mandated regulations and contracted payer contracts cause today's practice and facility administrators more than just headaches.  It can cost you large $.

It is important that both Physicians and Administrators know the importance of correct coding and documentation.   They should be involved in every part of the process.  Correct coding affects all methodologies of payment systems today, whether it is Physician, Outpatient, DRG's, Ambulatory Surgery or Provider based clinics.  Correct coding is the key to compliance and reimbursement and a Professional Coder can help.

By performing an internal chart review or utilizing independent expertise, you will enable the facility to compare codes to support documentation and help identify:

1. Over coding
2. Under coding
3. Unbundling issues
4. Misuse of modifiers
5. Medical necessity
6. Incorrect coding
7. Appropriateness of fee schedule
8. Services provided by physician extenders
9. Detection of incorrect write-offs or denials from carriers

The importance of education to staff and physician should be stressed, and coding guidelines should never mandate how a physician practices medicine but merely provide him knowledge of carrier guidelines for coverage issues.  A third-party review is recommended at least every two years to maintain outside objectivity.

Types of Chart Reviews

What type of chart review should you conduct?  Should it be retrospective or examining past services, or prospective which is done before the claim is sent?

Prospective Chart Review

Should be    

• Performed annually
• Done before implementing any new policies for compliance
• Done on all new providers to identify any problem areas before they get out of hand

May require

• A greater commitment by administration for staff and coding resources
• Further review of backend work such as posting and payment application

Retrospective Chart Review

Should be

• Done to provide a baseline for the facility
• Done to help the facility to determine what is coded correctly and what areas need improvement
• Done to help identify areas that will improve the organizations performance and reduce legal and compliance risks

May require

• Refunding to insurance carriers if errors are found
• More backend work administratively

Either one or both will help you identify risk areas and any potential loss of revenue.  By implementing internal policies and controls for coding and compliance, a coding chart review may find missed revenues, but also provides unnecessary losses and improves efficiencies.

Annette Grady, CPC-Ortho, CPC-H, CPC-I, CPC-P, CCS-P, FCS, PCS
TCN Senior Orthopaedic Compliance Auditor and Coder
Independent Healthcare Advisor
434 Yorkshire Lane
Bismarck, ND  58504
(701) 202-1488
agrady@bis.midco.net