Coding Audit Services to Optimize Compliance and Revenue Integrity

Accurate medical coding is crucial to confirming compliance and protecting revenue integrity. eValuator Coding Audit Services help you identify and address existing weaknesses in your clinical documentation and coding processes by delivering:

  • Market-leading coding audits from experienced professionals
  • Comprehensive reporting for root cause analysis and staff education
  • Rapid, sustainable ROI in confirmed compliance and protected revenue

Take Control of Revenue Integrity and Financial Performance:

Healthcare Coding Audit Services

Using eValuator Coding Audit Services, your organization will be able to accurately confirm compliance, protect revenue, capture care quality, and optimize staff productivity.

Inpatient services are the largest segment of many provider’s revenue, which makes it crucial to know your inpatient coding accurately reflects the acuity of care and services delivered. Streamline Health offers Inpatient Coding Audits to review MS-DRG and APR-DRG validation for inpatient charts.

In addition to code validation, these services can also deliver more comprehensive feedback that includes documentation and other elements essential to coder development and program optimization.

Many providers are experiencing a dramatic increase in outpatient (OP) services, which makes it more important than ever to be confident the supporting documentation and coding is accurate.   Given the specialized nature of many OP service lines, successful auditing requires a great deal of subject matter expertise.

Streamline Health’s team of auditors have decades of experience reviewing and optimizing OP cases, including the following specialties:

  • Emergency Department
  • Observation Services
  • Medical Oncology
  • Chemotherapy
  • Infusion Services
  • Interventional Radiology / Cardiology
  • Wound Care Services
  • Endoscopy Services
  • Pain Management Services
  • Outpatient Surgery

Our Outpatient audits are available as simple or as complex as you need. Some providers may simply need APC validation (pre or post bill), while others may want a more comprehensive review that provides a review of all diagnostic and procedural codes, including point of service and coder-applied CPT/HCPCS Codes with billing and reimbursement validation. By choosing the level of service based on your unique criteria, we can help ensure you get the results you need.

CMS and Managed Care Organizations are rapidly transitioning to risk-based reimbursement models.  Provider documentation and medical coding—both CPT and ICD-10— are the most influential measures of quality improvements through HEDIS, STARS and other pay-for-performance models. With up to 30% error rates on these medical coding efforts, it’s more important than ever to implement a rigorous compliance and audit management program.

Streamline Health Pro-Fee Audit Services will review your coding and supporting documentation to assess accuracy, generate comprehensive reports and provide detailed guidance to educate providers and coding staff on how to optimize compliant reimbursement.

Due to the unique nature of services delivered and the population served, LTAC coding represents a particularly difficult challenge. The MS-DRGs used for LTAC services require a highly specific skillset to understand and apply correctly. Our skilled auditors have thorough experience in reviewing these cases. Whether you need a simple MS-DRG validation or more thorough review that includes all diagnostic and procedural codes and supporting documentation, including POA indicators and Discharge Disposition status, Streamline Health can provide the LTAC Auditing support you need.

eValuator Coding Audit Services features a team of dedicated auditors—averaging 15+ years of experience—who thoroughly understand the complexities behind coding accuracy in today’s healthcare environment. Leveraging this vast experience and proprietary technology, these services can help identify the systemic challenges behind lost revenue and compliance exposure. These insights are then translated into a customized educational plan to help address the root causes behind your coding issues.

Healthcare Coding Compliance for Revenue and Reimbursement Integrity

For many decades, coding and documentation practices have impacted healthcare providers’ operational and financial performance. As the market moves to more value-based reimbursement, the need for accuracy will become even more pronounced.

Streamline Health’s eValuator Coding Audit Services are the most impactful option to identify, improve and sustain coding and documentation best practices. Choosing the best approach to audits is crucial to ensuring your efforts result in meaningful performance improvements. While there are common issues that impact coding performance, every provider has unique elements inherent to their organization that effect coding accuracy and productivity. As such, coding and documentation audits need to be aligned with your organization’s specific needs in order to effectively analyze, troubleshoot and correct issues as well as establishing sustainable performance improvements.

Pre-billing audits offer your organization the greatest opportunity to address coding issues in a timely and effective manner. In addition to preventing underpayments or denials based on coding errors, pre-bill audits also help prevent exposure to compliance risks. Pre-bill audits focus on DRG validation and involve review of diagnosis and procedure codes, POA indicators, HAC and PSI issues, discharge disposition status as well as
physician documentation practices.

Post-billing audits include DRG validation and can also incorporate a more extensive review of all codes, but if under- or over- coding is identified, time-sensitive re-submission is required to address the issues.

Some audit service providers utilize random or stratified random approaches to determine coding audit samples. Random audits are usually unstructured and address a broad range of coding and documentation practices. Accounts included in stratified random audits will address specific DRGs, coders, physicians, codes or service lines, and can sometimes provide insights into previously identified issues and targets.

Focused audits are highly structured with selected cases identified using data analytics that drill down into coded, financial and demographic data. Outcomes of focused coding audits identify those instances with the greatest opportunity for revenue integrity and performance improvement, ensuring maximum impact on current cases while helping identify training needs for coder development.

Thanks to our eValuator rules engine, Streamline Health performs highly focused audits that target the exact cases with the greatest opportunity for improvement.

Whether the audits occur pre-bill or post-bill, some providers may choose to audit those cases where payment outcomes are the primary focus. In our DRG Validation audits, Streamline Health reviews those coded and demographic data elements that impact DRG and APC assignment/payment and support
revenue integrity. In other instances, the provider may seek a more comprehensive audit approach with review of all assigned codes regardless of payment impact. In our Coding Validation audits, Streamline Health reviews all diagnosis and procedure codes and identifies trends and patterns in overall coding accuracy.

In addition to reviewing/correcting chart details, Streamline Health can also provide summary and detailed reports that support root cause analysis, coder education and documentation improvement initiatives. Along with identifying and tracking your audit outcomes, our reporting delivers actionable insight to develop performance improvement plans for your coders (on staff or outsourced) and clinical documentation staff.

Our flexible, robust reports include all data elements that are captured in our audits, including DRG Accuracy by Coder, Coding Errors by Coder, DRG Change by Original DRG, and Comparative Reason Grouping by Facility.