Physician Practice Coding/Billing Review

In coding and billing compliance reviews of Physician Practices, St. Clair uses an "AHIMA credentialed" Senior Consultant with computer access to software for such updated coding resources as: Coding Clinic, CPT Assistant, National Correct Coding Initiative (NCCI) edits, and CMS regulations.

For each medical case, St. Clair checks the accuracy of the coding for patient office visits and associated ancillary services (e.g., injections, laboratory, and radiology), submitted on the CMS 1500 billing form, against the clinical record documentation and the applicable coding guidelines. For the surgery performed on each surgical case, we assess the accuracy of the coding, submitted on the CMS 1500 billing form, against the clinical record documentation and the applicable coding guidelines. The scope of the surgical case review can be expanded to check the coding accuracy of the office visits and associated ancillary services during the applicable global billing period. Also, for each patient office visit, St. Clair assesses the accuracy of the Evaluation & Management (E&M) service level assigned.

After the review performance, a draft report of findings and recommendations, with supporting rationale, will be provided for consideration to the Practice in advance of an exit conference call. For all of our recommended coding changes, St. Clair will provide the rationale citing applicable coding guidelines and/or clinical record documentation. After obtaining sign-off as to having answered all Practice questions regarding the draft report, St. Clair will issue the final report.

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