From the January/February 2022 issue of HealthCare Business News magazine
7. Reduce denials and associated costs for claims rework, audits, and appeals
Daily pre-bill reviews of Medicare records and other payers continually drive coding and documentation integrity, which based on our estimates can yield a 700% or more ROI annually.
Steps to improve your CDI program through effective pre-bill review
There are certain steps any healthcare organization can take to make sure they conduct an effective pre-bill review.
Step 1: Identify documentation and coding vulnerabilities. Perform an initial assessment (i.e., 30-day, 90 day) documentation and coding assessment to determine accurate MS-DRG assignment – particularly high frequency or high impact DRGs. Look for common errors that typically result in revenue loss and compliance risk under value-based contracts and population management incentives.
Pinpoint vulnerabilities through data analysis, chart reviews, and CDI process assessments, such as:
• Incorrect diagnosis and procedure code assignment
• Overlooked opportunities for application of coding guidelines
• Non-specific physician documentation where conditions are suggested by clinical indicators
• Compliance risks including code assignment and conditions that lack clinical validity
• Errors in coding complications of medical or surgical care
Step 2: Incorporate common errors into a daily pre-bill review process. Each chart should be reviewed pre-bill noting potential missed query opportunities based on clinical indicators present in the record. Ideally, the team providing these reviews possesses advanced clinical acumen and clinical coding expertise to accurately perform the reviews and provide recommendations that integrate evidence-based clinical medicine and coding rules and guidelines. The combination of this expertise (physician and clinical coding analyst) ensures that the correct principal diagnosis is selected. Correct MS-DRG selection is key to revenue recovery and protection. Note, the reviews should be performed within a 24-hour turnaround time. Ideally, organizations would implement a similar strategy reaping rewards almost immediately.
Step 3: Use pre-bill reviews to drive concise and pertinent education for physicians, coders and CDI specialists. Physician documentation is essential to reimbursement, profiling, and performance measures. It is, however, most important for patient care. Information gathered from pre-bill reviews can be used to design targeted physician education sessions that include real-life case examples. This peer-to-peer specialty-directed physician education helps physicians ensure that patient severity and risk are reflected in the coded data associated with the care they provide. It allows hospitals to customize their approach for each service line. Equally important, topics can be prioritized and incorporated into weekly seminars to guide education for coders and CDI specialists for knowledge transfer and enhanced compliance.
