ICD-9-CM and/or ICD-10-CM/PCS Coding Accuracy and MS-DRG Focused Audit

  • Quality Review of inpatient medical records following government and coding guidelines.
  • OIG focused MS-DRGs reviewed.
  • Evaluation in coding accuracy in conjunction with medical record documentation.
  • Review for physician documentation deficiencies, correct code and MS-DRG assignment.
  • Identify cases where increase or decrease adjustments are necessary.   

    Educate Coders & Physicians on Audit Findings.

Ensure Coders Understanding of Correct Coding Initiative Edits.

ICD-10-CM/PCS Audits
Review for appropriate:

  • Assignment of ICD-10-CM diagnosis codes.
  • Assignment of ICD-10-PCS procedure codes.
  • Educational feedback on coding findings.
  • Documentation in the medical record to support code assignment.

ICD-10-CM/PCS Education
Provide ICD-10-CM/PCS Education:

  • Utilize training books published by AHIMA Press.
  • One week intense education and training on site utilizing training books published by AHIMA, and practice coding hospital medical records.
  • Review case studies and identify physician documentation deficiencies.
  • Our instructors are AHIMA ICD-10-CM/PCS approved.

Ambulatory Surgery Audits
Review and analyze:

  • Coding accuracy and proper assignment of ICD-9-CM diagnosis codes.
  • Proper application of CPT coding guidelines and principles.
  • Proper assignment of CPT and HCPCS Level II modifiers.
  • UB-04 billing forms for accuracy in representing the services provided in conjunction with the medical record documentation.

Quality Monitoring & Auditing Service
Our consultants can audit and monitor your coding and documentation quality on a monthly or weekly continuous basis

  • We will provide continuous education and training for all coders.
  • Assist in the implementation or revision of a documentation enhancement program.
  • Continuously monitor documentation and coding quality.
  • Monitors are customized per facility's needs and desired outcomes.
  • Enforce coding guidelines.
  • Improve documentation quality.
  • Submit statistics to administration.
  • Implement and monitor coding, discharge summary reconciliation, and prospective
    review process.
  • MS-DRG versus paid MS-DRG report monitoring.
  • Educate and train coders on how to educate physicians.
  • Assist in physician education.
  • Educate and train new coders.
Documentation Solutions, LLC ::: PO Box 634, Dearborn Heights, MI  48127-0634 ::: 734-838-0234