ICD-9, HCPC and CPT Code Review
- We review bills to ensure correct usage of industry standard coding of diagnoses codes and various standard procedure code sets.
- Our process supports the American Medical Association's guidelines for billing and coding.
Reasonable and Customary Rates
- We use a national database comprised of provider charges for each geographical area within the US to evaluate the charges for a particularly provider.
- Evaluation of each DME claim including reimbursement recommendations for custom-fitted orthosis and prosthetics.
- DME pricing for both rental purchase and rent-to-purchase agreements.
State Specific Fee Schedules in NY, PA, HI, UT, and NJ
- In these states, specific fee schedules have been adopted by the various legislatures for the pricing of auto claims. We support all specialty tables.
Review of Bundled and Inclusive Services
- We review each bill to ensure that providers are adhering to standard billing practices in regards to services that should be combined into a single code or billing an extra code for a service included in another.
Evaluation of Hard and Soft Duplicate Bills
- Hard Duplicates are bills where the same claimant, same date of service, same service, and same provider are billed a second time.
- Soft Duplicates are bills where some of the information contained may match bills already priced, but that are not 100% the same.
- Our staff investigates all soft duplicate bills to determine duplicate status and recommend payment where appropriate.
Pharmacological Evaluation
- AWP pricing service available.
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Hospital and Facility Bill Review |
DRG - Diagnosis Related Groups
- Reported diagnoses and treatments are matched to the industry standard DRG codes for evaluation of treatment. DRG codes are adjusted for patient condition, age, complications or discharge status.
- Reimbursement is based on geographical region of the facility where service was rendered and the assigned DRG code.
RBRVS - Resource Based Relative Value System
- This pricing option is available in situations where a DRG's pricing option is not available and uses standard US Federal Register data for each year to base payment recommendations.
Ambulatory Surgical pricing
- NY PAS codes supported
- DRG or Outpatient HCPC coding available depending on case. Bills are evaluated for proper use of ICD-9, HCPC's and Rev codes
Pharmacological charges and Supplies are reviewed
- AWP pricing available when not included in DRG reimbursement.
DME
- Payment recommendations provided separately when not included in DRG criteria.
Medical review for appropriateness of care and medical necessity
- All Inpatient and Ambulatory bills are evaluated by our medical staff to ensure continuity of care; medical necessity and accident or injury relatedness
- Medical records are compared to UB92 form to ensure proper billing and coding.
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