Audit Services - Hospital Support

Intermittent Consultation Service

QMCG professionals are available by email, fax or telephone to respond to hospital staff questions concerning coding and claims submission issues - a different level of "help desk". The service is charged in 15 minute increments and responses are most often accompanied by copies of supporting documentation. To become an on-going consultation client, contact QMCG by telephone at (614) 227-4848, by fax at (614) 227-2390 or by email to info@qmcq.com.

QMCG's review of the CDM provides a line-by-line review of the coding in your CDM. The comprehensive audit includes interviews with clinical and billing staff. We invite billing staff to all interviews to bring copies of any claims representing a billing problem for each department and identify the coding/billing issue solvable by changes in the charging process or CDM. A written report with supporting documentation will be provided to assist with the implementation of necessary changes to update your CDM with current state and federal regulations.

A unique feature of the QMCG CDM review is submission of supporting documentation for any significant CDM change. This not only assists with implementation of changes, but also increases hospital staff awareness of billing and coding resources.

Many facilities derive 35-50% of inpatient review from Diagnostic Related Groups (DRGs) or managed care/case mix based payers. Thousands of rules are hinged on accurately and completely assigning all diagnostic and procedure codes. QMCG can help evaluate the accuracy of the ICD-9-CM coding and assure that complications and co-morbidities are being accurately captured so that the appropriate DRG is assigned. This review includes an audit of the medical record to assure that the documentation supports the reported ICD-9-CM diagnosis and procedure codes. Any coding changes are detailed in a report and the DRG is re-calculated based on any recommended coding changes. A report listing each claim/medical record reviewed is provided with supporting documentation.

An outpatient claims review consists of a line item audit of the UB-04 with the medical record looking at:

• Accuracy of ICD-9-CM diagnosis codes;
• Accuracy of HCPCS/CPT coding including E & M levels;
• Appropriate use of revenue codes;
• Appropriate use of modifiers;
• Missing charges;
• Items failing Medicare's Outpatient Code Editor.

A detailed report listing findings in the above categories will be prepared by QMCG.

The goal of the bill audit is to assure that all items listed on a hospital bill are supported by documentation in the medical record. Random bill audits should be performed yearly and after any significant change to the chargemaster (CDM). QMCG also offers defense audits to assure that bill audits by external auditors are accurate and also take into consideration undercharges.

QMCG's trained professional auditors review the hospital's itemized statement with medical record documentation looking for:

• Unbilled services

• Accuracy of billed services

• Data entry errors
• Proper bundling of charges

The auditors make any recommendations for additions/deletions based on the hospital's general practice.

The audit can be performed on-site or with records sent to our office.

Educational programs are always in need, but of the utmost importance when new programs are being implemented, when specific training needs are identified and when required by the provider's compliance plan. QMCG consultants tailor educational programs to the specific needs of each provider. Some topics which have been addressed include:

• Use of modifiers
• Introduction to ICD-9-CM coding
• Advanced ICD-9-CM coding
• CPT and HCPCS coding
• Evaluation and Management services
• Observation status policies and procedures
• Introduction to the Medicare outpatient prospective payment system (Ambulatory Payment Classification)
• Rehabilitation services
• Medical necessity and local coverage determinations
• Advanced beneficiary notices
• Introduction to Medicare Payment Systems

Keeping a hospital's charge description master (CDM) coded in compliance with government regulations is a time consuming/tedious task. A newsletter specific to Ohio's Medicare and Medicaid coding issues is published periodically and is intended to assist hospital staff in keeping abreast of changes. The articles will be short and address revenue and HCPCS coding.