Inpatient / Outpatient (IPPS/OPPS) Full Service Program

The scope of the engagement includes on-site review and technical expertise. Our consultant specialists will validate records and corresponding billing claims for:

• Coding assignments (ICD-9-CM, CPT, and HCPCS) 
• Diagnosis supports services performed 
• Validation of procedure charging 
• Review documentation for quality 
• Medical necessity 
• Physician orders and certifications/re-certifications 
• Physician signatures 
• Nurse's notes

Value Added Benefits for this Service: 

• Ensure coding and billing compliance 
• Enhanced coding techniques 
• More knowledgeable staff 
• Quantifiable results

Acute Care

Teaching Facilities

Critical Access Hospitals

Long Term Acute Care

Inpatient Rehab Facilities

Skilled Nursing Facilities

ASC

The program includes analysis of Client's outpatient/ancillary services and clinic services impacted by CMS OPPS: review of entire CDM for outpatient/ancillary (including clinics) line items for accuracy of the CPT/HCPCS, UB revenue code, and modifier assignment for compliance with federal and fiscal intermediary rules and regulations, price comparison vs. allowable reimbursement levels, and review descriptions for meeting Client's internal standards. Additionally, our consultant specialists perform reviews of outpatient medical records and billing documents to ensure coding (ICD-9-CM, CPT, HCPCS) compliance with current guidelines and optimal reimbursement from all payors. 

Developed to ensure that the Client is compliant in its review activities of its billing and coding practices and compliance obligations under the Corporate Integrity Agreement (CIA) and Medicare rules and regulations, HMI will perform the Claims Reviews required under the Client's CIA, prepare required reports for the OIG, make recommendations for Client's corrective action plan, and provide necessary staff training and education on current coding and billing methodologies.