Corporate Compliance

Ambulatory payment classification monitoring

Healthcare Auditing Weekly, August 30, 2005

Over the next two weeks, we will discuss ways to ensure compliance with coding and claim development laws and to prevent APC reimbursement losses from documentation or charge-capture problems. It is important to begin by gathering a toolkit.

Your toolkit should contain the following:

  • Relevant code books (CPT and HCPCS Level II)
  • Medical records
  • Audit trail of codes assigned by health information management (HIM) coding staff
  • Printed coding summary from the HIM abstraction system or encoding software
  • UB-92
  • Itemized bill
  • Medicare remittance advice
  • Hospital chargemaster
  • List of high-volume CPT procedures, such as gastrointestinal endoscopies
  • List of high-dollar (charges or APC reimbursement) CPT procedures, such as pacemakers, brachytherapy, or chemotherapy
  • List of problem-prone CPT procedures by body system
  • List of CPT code pairs
  • List of procedures paid at 150% when modifier -50 is appended to the CPT code

      Look for next week's issue when we discuss selecting cases and reviewing codes.

        The above tip is an excerpt from the book "Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas." Copyright 2004 by HCPro, Inc. This book is a step-by-step, practical manual that offers sample audit programs for the most troublesome areas that a hospital must audit. The binder and CD-ROM are filled with actual audit programs used by auditors and compliance officers in the field. Click here for more information or to order your copy today.

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