www.codebusters.com

‣ !Designed!Around!Blended!Workforce!Model!Requirements:Recruitment!process!outsourcing!(RPO)!>!Direct!Hire,!Temp!to!HireFull!Cme/Part!Cme!Contract!>!Instant!On,!As!Needed!AvailabilityHIM/Revenue!Cycle!Specialists!and!Supervisors

‣! HR!and!ConCngent!Workforce!Planning!SMEs:On>site,!Off>site,!24/7!accessible!Account!Management!TeamMarket!rate!analysis!and!projecConsCompliance!management!systemStrategic/Dynamic!Business!Review

STRATEGIC SOLUTIONS OVERVIEW

‣!!!HIM!/!Revenue!Cycle!SMEs:!Full!Cycle!SoluCon:!DocumentaCon,!Coding,!Billing,!External!Data!ReporCng360!degree!performance!managementProducCvity!analysisConcurrent/RetrospecCve!Compliance!Audits

‣ Visibility!into!specialized!labor!pool!availability!by!locaCon!!(Talent!GPS)

‣ !HIM!focus!talent!management!system!(onsite!and!remote):Career!Path!DevelopmentLearning!Management!(ICD>10,!CEUs)

Strategic Account Management

Talent Benching Center of Excellence - Talent Benching by Location

Minority / Small Business HIM / HIT

‣ Beta!program!which!can!be!easily!launched

‣ Test!for!ROI/ROR!at!3!and!6!month!intervals

‣ Scale!up,!working!toward!long>term!contract!

Scaleable Solution

www.codebusters.com

888-978-6198

9415 Culver Blvd

Culver City, CA 90232@CodebustersInc

CodebustersInc

‣ Tax!credits!may!be!available!to!ZeroChaos>UCSF!if!programs!or!business!units!are!using!federal!and!state!grants!for!funding

‣ SupporCng!CA!Based!SBE/MBEs!is!Good!Business

‣ HIM/!HIT!is!main!Codebusters!Core!Competency

‣ Proven!Past!Performance!with!University!Affiliated!Hospitals!and

‣ Working!in!an!MSP/VMS!model

‣ Real!Cme!market!rate!analysis

‣ Longevity!discount!model

‣ Payroll!Services/Employer!of!Record!SoluCon

‣ Share!best!pracCces‣ Refine!program!based!on!upcoming!iniCaCves!(internal!and!external)

‣ Labor!and!regulatory!landscape

Executive Roundtable

Dynamic Pricing

‣ HIT/HIM Staff Augmentation‣ Medical Coding‣ ICD-10 Education‣ Oncology Data Management‣ Audit and Compliance‣ Clinical Documentation Improvement‣ SOW and Project Management‣ Employer of Record Solutions‣ Bespoke Solutions, Consulting and High Touch Client Care

EXECUTIVE SUMMARYCodebusters*delivers*innova0ve*medical*coding*solu0ons*to*maximize*revenue*and*minimize*risk*across*the*healthcare*con0nuum.*We*leverage*technology*to*increase*coding*accuracy,*produc0vity,*and*availability.*Client*opera0onal*needs*inform*system*design,*crea0ng*revenue*cycle*efficiencies*that*reduce*costs*and*eliminate*payment*denials*and*variances.*Payer*compliance*professionals*ensure*a*clear*link*between*clinical*documenta0on*and*code*assignment,*allevia0ng*the*complementary*risks*of*RAC*recoupment*and*underCbilling.*Providers*have*the*flexibility*to*work*with*coders,*auditors,*and*documenta0on*professionals*remotely*or*onsite.*Codebusters*offers*business*cri0cal*solu0ons*and*longCterm*partnerships,*allowing*providers*to*focus*on*pa0ent*care.

Codebusters*has*been*providing*Return*on*Investment/*Return*on*Rela0onship*focused*solu0ons*since*1998,*and*has*been*a*specialized*services*partner*to*organiza0ons*such*as*The*County*of*Los*Angeles*–*Department*of*Health*Services,*Dignity*Health,*USC*&*UCLA*affiliated*hospitals,*Na0onal*HMO/PPO*Providers*and*other*acute*care*facili0es.*Our*team*of*SMEs*(Subject*MaYer*Experts)*have*been*called*upon*by*For*Profit,*Non*Profit,*Faith*Based,*Rural*and*Highly*Complex*Health*Systems*to*provide*innova0ve*services*and*strategic*counsel.*We*are*commiYed*to*providing*excep0onal*value*to*our*clients*and*posi0vely*impact*the*financial*wellCbeing*of*their*organiza0ons.

‣ Quality Assurance Audits‣ Billing and Payroll‣ Client Business Reviews‣ Communications Management‣ Contract Compliance‣ Customer Service‣ Discovery & Client Consultations‣ Diversity and Inclusion‣ Human Resources

Our*specialized*team*of*talent*acquisi0on*professionals*and*recruitment*agents*with*proven*past*performance*in*staffing*H.I.M.*posi0ons,*screening,*background*checking,*talent*benching,*on/off*boarding*and*managing*a*high*performance*con0ngent*workforce.

CODEBUSTERS, INC. RECRUITMENT CENTER OF EXCELLENCE:

ACCOUNT MANAGEMENT TEAM:

‣ Innovation & Program Enhancement‣ Learning Management‣ Metrics‣ Program & Project Management‣ Recruitment / Staffing‣ ROI‣ Reporting‣ Service Level Agreement

Management

ACCOUNT MANAGEMENT STRUCTURE

Team%Codebusters%is%commi0ed%to%providing%quality%staff%augmenta9on%services%and%demonstra9ng%added%value%to%its%clients%and%their%stakeholders.%Below%is%an%overview%of%the%Codebusters’%management%team%which%support%our%contract%end%users.%Our%account%structure%is%based%around%working%with%a%broad%based%of%staffing%models%and%vendor%management%technology%tools.

Vincent'Kobayashi'–%CEO'&'General'Managervincent@codebusters.com | 888.978.6198 Ext. 700%Mitch'Cardoza,'SPHR'–%Vice'President,'Client'SoluAonsmcardoza@codebusters.com | 888.978.6198 Ext. 704

‣ Establish%communica9on%protocol‣ Interview%end%users%and%department%managers,%set%expecta9ons‣ Local%service%and%opera9ons%support‣ Ensure%compliance‣ ICDI10%educa9onal%support%/%training‣ Set%up%and%provide%consolidated%repor9ng%examples‣ Conduct%coding%quality%and%produc9vity%reviews%based%on%client’s%needs‣ Collaborate%for%successful%program%roll%out‣ Client%rela9ons‣ Market%intelligence‣ H.I.M.%&%C.W.O.%SMEs‣ Quality%improvements

EXECUTIVE SPONSORS

Jeannine'Ratliff%–%Human'Resources'&'Account'Managerjratliff@codebusters.com | 888.978.6198 Ext. 701%‣ %%%%Work%with%client%organiza9on%to%understand%and%an9cipate%needs%–%discovery%audit‣ %%%%Create%dedicated%recruitment%strategies‣ %%%%Conduct%demand%planning%and%forecas9ng%mee9ngs‣ %%%%Execute%client’s%preIemployment%and%screening%requirements‣ %%%%%Compliance%&%co%employment%management‣ %%%%Manage%per%Contract%SLAs,%Metrics%&%Rules%of%Engagement‣ %%%%Take%hands%on%approach%–%feedback%and%constant%communica9on

PROGRAM MANAGEMENT | COMPLIANCE | ONBOARDING

MANAGEMENT

Tiffany'Emigh'–'Sr.'Recruiter'&'Project'Managertemigh@codebusters.com | 888.978.6198 Ext. 702%‣ %%%Customized%orienta9on‣ %%%%%Associate%conflict%resolu9on‣ %%%%Performance%coaching‣ %%%%Performance%feedback‣ %%%%Market%recrui9ng%and%talent%benching‣ %%%%Timesheet%management‣ %%%%Execute%clientIspecific%reten9on%program‣ %%%%Ongoing%associate%skill%training‣ %%%%ReIdeployment

RECRUITMENT MANAGEMENT | CONTINGENT ASSOCIATE

MANAGEMENT

At#Codebusters,#our#prac0ce#of#a2rac0ng,#screening,#placing#and#training#the#top#5%#of#HIM#professionals#benefits#our#healthcare#clients’#needs#to#op0mize#revenue#capture,#navigate#ever#changing#regulatory#requirements,#and#deliver#mission#cri0cal#health#informa0on#management#and#technology#business#objec0ves.

Our#talent#management#team#has#deep#HIM#experience,#directly#affec0ng#our#clients’#bo2om#line#through#mi0ga0ng#the#tremendous#costs#of#a#Bad#Hire.#Our#team#of#HIM#professionals#posi0vely#impacts#recruitment#of#key#individuals,#reducing#opera0onal#and#HR#expenses.#It#is#no#secret#that#large#healthcare#HR#departments#face#some#of#the#most#daun0ng#challenges#of#a#genera0on.#They#must#deliver#highly#specialized#professionals#to#every#department#in#order#to#keep#pace#with#the#increases#in#census#that#the#ACA#is#an0cipated#to#bring,#on#top#of#rolling#out#next#genera0on#EHR#systems,#and#tackling#the#demands#of#ICDP10#prepara0on.#

It#is#also#common#knowledge#that#many#HR#teams#do#not#have#adequate#budgets#to#maintain#the#recruiters#they#need.#As#such#the#risk#of#making#a#“bad#hire”#is#a#very#real#challenge.#Depending#on#the#posi0on,#a#bad#hire#could#set#you#back#anywhere#from#$25,000#to#$300,000.#That’s#according#to#researchers#at#the#Na0onal#Business#Research#Ins0tute#(NBRI).#Based#on#their#research,#66%#of#employers#said#they#experienced#nega0ve#effects#of#bad#hires#in#2012.

Of#these#employers,#many#of#them#in#the#healthcare#space,#37%#said#the#bad#hire#nega0vely#affected#employee#morale.#Another#18%#said#the#bad#hire#nega0vely#impacted#client#rela0onships.#And#10%#said#the#bad#hire#caused#a#decrease#in#sales#or#produc0vity.

Researchers#examined#five#main#factors#to#help#them#es0mate#the#cost#of#a#bad#hire:

‣ ##Loss#in#produc0vity#–#the#annual#salary#of#the#employee

‣ ##Training#costs#–#25%#of#the#annual#salary#of#the#employee

‣ ##HR#costs#–#calculated#using#the#average#HR#Generalist’s#salary#+#others#on#HR#team‣ ##Interviewing#costs#–#calculated#using#the#average#HR#Generalist’s#salary,#screenings,#and#Employment#ads#for#a#new#hire;#anywhere#from#$100#to#$1,600

When#these#factors#are#combined,#companies#take#a#huge#hit#to#their#wallets.#The#lowest#paying#jobs#–#like#fast#food#cook#and#farm#worker#–#oeen#earn#a#salary#between#$18,600#and#$20,320.#But#a #bad#hire#in#one#of#these#posi0ons#can#cost#a#company#an#average#of#$25,000.

COST PER POSITION

It’s#a#similar#situa0on#for#the#highest#paying#medical#and#nonPmedical#jobs.#Experienced#workers,#managers#and#professionals#earn#an#average#salary#somewhere#between#$80,000#and#$130,000.#A#bad#hire#in#those#posi0ons#can#cost#employers#anywhere#from#$152,000#to#$220,000.

It#gets#even#worse#for#the#highest#paying#medical#jobs,#which#earn#salaries#between#$191,000#and#$233,000.#The#cost#of#a#bad#hire#in#one#of#these#posi0ons:#nearly#$300,000.

HR VALUE PROPOSITION

So,#if#bad#hires#cost#so#much#money,#how#do#they#keep#finding#employment?#For#starters,#10%#of#respondents#said#the#recession#has#made#it#hard#to#pay#staff#to#go#through#applica0ons#looking#for#the#best#candidates.#The#reason#43%#of#companies#made#what#turned#out#to#be#a#bad#hire:#They#needed#to#fill#the#job#quickly.

SOLUTION

Codebusters,#Inc.#has#been#in#the#business#of#iden0fying#and#represen0ng#the#most#competent#health#informa0on#professionals#since#2000.#With#our#SME#Talent#Acquisi0on#Team#aligning#with#your#HR#and#Recruitment#Team,#the#results#are:#Excep0onal#Talent,#Quan0fiable#Value,#and#Measured#Performance.#Our#company#mo2o#is#“Together#We#Are#Stronger!”#We#have#extensive#experience#working#in#high#velocity#MSP#recrui0ng#environments#with#complex#onPboarding#systems,#where#frequent#score#cards#compare#our#performance#against#compe0ng#suppliers.#We#employ#the#latest#technology#in#applicant#tracking,#candidate#evalua0on,#and#performance#management,#allowing#us#to#maintain#a#full#audit#trail#at#each#stage#of#the#process.

“Why Do Companies Make Bad Hires?”

Types of engagements we establish with clients:

‣ Contract‣ TempPtoPperm

‣ Direct#Hire‣ ProjectPbased‣ RPO

A#few#of#the#clients#we#serve:! USC!and!UCLA!University!Health!Systems! Los!Angeles!County!Department!of!Health! Dignity!Health

We#understand#Knowledge0Intensive#Services:#KIS#(“Professional#Services”)#are#important#and#vital#to#the#success#of#your#organizaBon#and#HIM,#HIT#&#Revenue#Cycle#Business#Units.#Team#Codebusters#also#realizes#that#when#partnering#with#a#network0wide#Staff#AugmentaBon#and#Professional#Services#organizaBon#to#serve#under#a#Master#Vendor#or#Preferred#Vendor#contract,#our#focus#needs#to#align#with#strategic)procurement)metrics#and#SLAs.

We#understand#the#deep)level)of)commitment,)resources,)and)high)performance#needed#to#not#only#succeed,#but#thrive#as#an#organizaBon0wide#supplier#partner.#With#this#philosophy#and#business#foundaBon#in#mind,#Codebusters,#Inc.#addresses#the#following#when#contracBng#with#a#Strategic#Account#client#partner:

‣ Minority and Woman owned business‣ Common cooperation partners‣ Contract compliance, SLA adherence, and continuous improvements‣ Proven ROI capacity‣ Financially stable ‣ Continuous process improvement‣ Culture of innovation‣ Intimate knowledge of HIM‣ National network / local presence‣ Proven past performance with various facility types‣ Proven past performance delivering exceptional candidates‣ References / experience of the offered SME team‣ Technical capability‣ Total Cost of Ownership‣ Trust

PROCUREMENT VALUE PROPOSITION

‣ HIT/HIM Staff Augmentation‣ Medical Coding‣ ICD-10 Education‣ Oncology Data Management‣ Audit and Compliance‣ Clinical Documentation Improvement‣ SOW and Project Management‣ Employer of Record Solutions‣ Bespoke Solutions, Consulting and High Touch Client Care

Codebusters#delivers#innovaBve#medical#coding#soluBons#to#maximize#revenue#and#minimize#risk#across#the#healthcare#conBnuum.#We#leverage#technology#to#increase#coding#accuracy,#producBvity,#and#availability.#Client#operaBonal#needs#inform#system#design,#creaBng#revenue#cycle#efficiencies#that#reduce#costs#and#eliminate#payment#denials#and#variances.#Payer#compliance#professionals#ensure#a#clear#link#between#clinical#documentaBon#and#code#assignment,#alleviaBng#the#complementary#risks#of#RAC#recoupment#and#under0billing.#Providers#have#the#flexibility#to#work#with#coders,#auditors,#and#documentaBon#professionals#remotely#or#onsite.#CodeBusters#offers#business#criBcal#soluBons#and#long0term#partnerships,#allowing#providers#to#focus#on#paBent#care.

COMPANY PROFILE

Codebusters#has#been#providing#Return#on#Investment#/#Return#on#RelaBonship#focused#soluBons#since#2000,#and#have#been#a#specialized#services#partner#to#organizaBons#such#as#Kaiser)Permanente,#The)County)of)Los)Angeles)–)Department)of)Health)Services,#Dignity)Health,#and#USC)&)UCLA)affiliated)hospitals.#Our#team#of#SMEs#(Subject#Ma\er#Experts)#have#been#called#upon#by#For#Profit,#Non#Profit,#Faith#Based,#Rural#and#Highly#Complex#Health#Systems#to#provide#innovaBve#services#and#strategic#counsel.#We#are#commi\ed#to#providing#excepBonal#value#to#each#company#and#aim#to#posiBvely#impact#the#financial#and#operaBonal#well#being#of#your#organizaBon.

MEDICAL CODING SERVICES

Codebusters*specializes*in*providing*coding*solu4ons*for*acute*care*facili4es*and*physician8based*clinics.*Our*coders*can*be*deployed*to*work*on8site*or*from*a*remote*loca4on.*We*assist*providers*in*establishing*both*temporary*and*fully*outsourced*solu4ons.*We*are*dedicated*to*delivering*the*most*proven*and*competent*coders*at*a*moment’s*no4ce.**Given*the*ever8changing*nature*of*the*field,*we*con4nuously*train*all*of*our*people*to*ensure*they*are*fluent*with*the*latest*developments.*Our*goal*is*to*help*our*clients*op4mize*their*staffing*levels*through*both*increases*and*decreases*in*census,*allowing*them*to*maintain*exactly*the*staff*necessary*to*quickly*convert*accounts*receivable*to*ready*money.*We*start*by*listening*to*your*business*needs.*Every*hospital*faces*unique*challenges*and*risks,*collects*different*informa4on,*and*has*its*own*workflow*built*around*its*individual*department*structure.*Codebusters*account*managers*work*hand*in*hand*with*hiring*managers*so*that*we*bring*them*the*best*people*the*first*4me.*We*can*create*custom*pre8screening*exams*that*mimic*the*exact*types*of*coding*scenarios*for*which*you*need*coders*to*demonstrate*proficiency.*All*of*the*candidates*that*we*present*will*have*met*specified*cer4fica4on,*experience,*and*skills*based*requirements.*We*are*dedicated*to*establishing*workforce*solu4ons*that*enable*providers*to*increase*produc4vity,*reduce*risk,*and*improve*revenue*capture.*By*taking*a*careful*analysis*of*the*cost*of*the*current*coding*solu4on,*produc4vity,*accuracy,*and*revenue*metrics,*we*are*able*to*demonstrate*the*value*added*benefits.*Through*best*in*class*recrui4ng,*staffing*exper4se,*and*technology*innova4on*we*are*able*to*help*our*clients*achieve*process*excellence*within*their*HIM*departments.*With*Codebusters*exper4se*in*medical*coding*staffing*and*oversight,*our*clients*become*free*to*focus*on*pa4ent*outcomes.

INPATIENT CODING

Codebusters*offers*both*coding*and*audi4ng*services*for*inpa4ent*records,*Medicare*and*non8Medicare.*Each*coder/auditor*whom*we*present*to*a*client*must*undergo*a*thorough*background*check*and*proof*of*skills*tes4ng.*The*candidates'*skills*are*evaluated*against*tests*that*are*developed*in*conjunc4on*with*the*client.*Inpa4ent*coding*requires*sound*understanding*of*a*broad*range*of*complex*diagnoses,*procedures,*and*lab*results.*Coders*who*are*proficient*in*this*area*have*generally*had*several*years*of*experience*performing*medical*coding*in*an*acute*care*hospital*seRng.*The*strong*knowledge*of*anatomy*and*body*system*processes*that*comes*with*years*of*professional*experience*will*be*of*cri4cal*importance*for*ICD8108PCS.*The*coding*requirements*for*inpa4ent*encounters*contain*many*compliance*challenges.*Our*coders*become*in4mately*familiar*with*your*physician*query*procedures*in*order*to*provide*documenta4on*feedback*in*order*to*assist*the*client*in*full*revenue*capture.

Components)of)the)Inpa.ent)Review* ●***High*Revenue*RAC*Targets* ●***OIG*Work*Plan

* ●***Fraud*Alerts* ●***Top*10825*Surgeries* ●***Top*10825*MS8DRGs

* ●***High*volume,*high8risk*procedures

* ●***Top*10825*denials* ●***Top*10825*services*provided* ●***Review*of*modifier*usage

* ●***Inpa4ent*Outliers* ●***Consecu4ve*Inpa4ent*Stays* ●***Medical*Necessity

General)Audit)Topics* ●***High*Revenue*RAC*Targets* ●***OIG*Work*Plan

* ●***Fraud*Alerts* ●***Top*10825*Surgeries* ●***Top*10825*MS8DRGs

* ●***High*volume,*high8risk*procedures

* ●***Top*10825*denials* ●***Top*10825*services*provided* ●***Review*of*modifier*usage

* ●***Tests*ordered*were*actually*performed

* ●***Inpa4ent*Outliers* ●***Consecu4ve*Inpa4ent*Stays* ●***Medical*Necessity

Focused)Coding)Reviews* ●***Surgical*Complica4ons

* ●***Obstetrical*Complica4ons

* ●***Error*MS8DRGs

* ●***Diabetes*Mellitus

* ●***Dehydra4on*as*Principal*Diagnosis* ●***Gastrointes4nal*Bleeding* ●***OIG8iden4fied*paired/families*of*MS8DRGs

OUTPATIENT CODING

Codebusters*provides*medical*coding*and*audi4ng*services*for*a*wide*variety*of*outpa4ent*seRngs.*We*work*with*professionals*that*have*experience*in*facility*based*outpa4ent*observa4on*and*surgery*coding,*as*well*as*clinic*based*outpa4ent*coders.*Each*coder*or*auditor*that*we*work*with*must*show*experience*coding*in*the*client’s*seRng*type*and*pass*an*exam*specific*to*the*client’s*facility.*Exams*can*be*custom*tailored*to*ensure*the*candidate*has*the*specific*knowledge*to*do*the*job.*We*fully*understand*the*coding*requirements*for*observa4on*and*surgery*encounters*contain*many*compliance*challenges.*Codebusters*can*assist*providers*in*ensuring*complete*documenta4on,*capturing*correct*informa4on*in*the*chargemaster,*reviewing*code*assignment,*and*examining*medical*necessity*compliance.*Our*coders*provide*documented*feedback,*where*appropriate,*in*order*to*assist*the*client*in*full*revenue*capture.*Cer4fied*medical*coders*can*be*deployed*onsite*to*the*facility*or*off8site*through*remote*access*to*the*facility.*Hospitals*should*consider*performing*coding*reviews*prior*to*billing,*if*prac4cal.*This*kind*of*con4nuous,*real84me*audi4ng*can*iden4fy*pa]erns*of*problems*with*documenta4on*or*poor*coding*immediately.*Otherwise*quarterly*or*annual*reviews*should*be*performed*on*a*retrospec4ve*basis.

Same)Day)Surgery)CodingOutpa4ent*surgery*coding,*also*know*at*same*day*surgeries,*requires*a*very*thorough*knowledge*of*anatomy*to*appropriately*assign*CPT*codes.*Codebusters’*coders*ensure*all*procedures*have*a*corresponding*diagnosis*that*adheres*to*medically*necessary*payer*and*provider*guidelines.*Appropriate*assignment*of*modifiers*should*also*be*reviewed*as*it*affects*APC*assignment*and*thus*reimbursement.*APCs*should*be*reviewed*to*validate*appropriate*transmission*of*HCPCS*codes*to*the*grouper*and*the*claim*form.*If*the*record*shows*that*services*were*provided*but*not*charged,*then*the*department*responsible*should*receive*training*or*processes*be*revised.*Our*professionals*understand*the*intricacies*of*global*surgery*package*rules*so*that*providers*can*stay*in*compliance*with*this*very*complex*set*of*guidelines.

Review)Topics* ●***Modifier*Use

* ●***Podiatry*Procedures* ●***Cardiac*Catheteriza4ons* ●***Top*25*APC*groups*by*volume*and*charges

* ●***Procedure*and*diagnosis*codes*by*surgery*subsec4on*of*CPT

OBSERVATION CODING

Coding*and*billing*for*observa4on*services*are*a*common*source*of*compliance*concerns.*Pa4ents*are*put*on*an*observa4on*status*to*monitor*their*health*and**determine*if*it*is*necessary*to*admit*them*as*inpa4ents,*thereby*reducing*costs*of*care.*The*professional*and*facility*components*of*observa4on*coding*are*paid*based*on*a*specific*set*of*rules.*In*order*for*the*facility*to*receive*reimbursement*for*observa4on*services,*the*pa4ent*must*be*either*directly*admi]ed*to*observa4on,*or*come*from*the*ED*or*clinic*with*a*level*5*visit,*and*meet*certain*procedural*requirements*and*4me*thresholds.*Correct*physician*and*prac44oner*documenta4on*is*cri4cal*for*reimbursement.*All*procedures*must*be*documented,*including*ones*provided*through*the*ED*or*clinic.*Facili4es*must*also*make*sure*they*follow*proper*procedures*to*ensure*pa4ents*are*properly*screened*before*being*put*on*observa4on*status.*Care*management*plans*must*be*developed*for*admiRng*to*observa4on,*retaining*in*observa4on,*and*discharging*from*observa4on*to*acute*care,*home,*or*other*services*levels.**Observa4on*services*indicate*a*pa4ent’s*status*rather*than*a*place*of*service.**Observa4on*can*take*place*anywhere*in*a*hospital,*most*commonly*in*the*ER,*dedicated*observa4on*area,*or*on*an*acute*care*unit.*The*OIG*has*long*made*mis8classifica4on*of*short*stay*inpa4ents,*who*instead*should*have*been*put*on*observa4on*rather*being*admi]ed*as*an*inpa4ent,*a*major*point*of*inves4ga4on,*as*well*as*the*use*of*Condi4on*44*on*the*technical*component*claim*form.**Codebusters’*auditors*can*evaluate*care*management*paths*and*pa4ent*screening*protocols*to*ensure*correct*admi]ance*to*observa4on*status,*as*well*as*provide*training*to*prac44oners*on*proper*methods*to*document*observa4on*stays.

EMERGENCY DEPARTMENT

Hospital*emergency*departments*encompass*both*professional*and*technical*services.**Codebusters*provides*coding*and*audi4ng*services*for*both*the*facility*claim*and*physician*claim*in*an*ED*encounter.*Hospitals*bill*for*an*ED*visit*using*APCs*under*the*OPPS,*whereas*physician’s*will*bill*the*same*visit*under*the*Medicare*Physician*Fee*Schedule.*The*facility*collects*a*separate*payment*than*the*physician,*as*it*does*for*all*facility8based*inpa4ent*and*outpa4ent*visits.*Coding*and*audi4ng*considera4ons*and*procedures*differ*for*the*facility*and*physician*coding.*Professional*services*coding*for*the*ED*has*peculiari4es*that*make*it*different*from*E/M*coding*in*other*seRngs.*Audi4ng*of*facility*and*professional*documenta4on,*coding,*and*billing,*can*be*performed*onsite*or*offsite.

Coding)GuidelinesThe*facility*or*hospital*is*paid*under*OPPS,*where*an*APC*is*assigned*for*each*visit.*CMS*requires*the*assignment*of*a*level*of*service*code*(Evalua4on*and*Management*8*EM*8*code),*as*well*as*documenta4on*of*all*procedures*in*order*to*assign*APC*codes*for*reimbursement.*Unlike*DRGs,*more*than*one*APC*code*can*be*assigned*per*encounter.*Coders*must*be*sure*to*extract*all*documented*physician*and*nurse*procedures,*and*review*all*notes*to*ensure*proper*documenta4on*of*procedures.*Diagnosis*codes*must*be*present*to*establish*the*medical*necessity*of*the*visit,*as*defined*by*LCDs*and*NCDs.*Proper*modifiers*must*be*used*when*E/M*levels*and*procedures*are*both*coded*to*ensure*correct*payment.*Na4onal*guidelines*for*defining*level*of*service*do*not*exist.*CMS*has*directed*hospitals*to*develop*their*own*guidelines.*CMS*stated*that*the*“level*of*service*for*emergency*and*clinic*visits*should*be*determined*by*resource*consump4on*that*is*not*otherwise*separately*payable.”**EM*code*should*reflect*hospital’s*resource*consump4on,*not*the*physician’s.*Physician*and*facility*EM*code*may*not*be*the*same.*Facili4es*must*be*sure*they*are*consistently*applying*jus4fiable*rules*for*level*assignment.*All*procedures*and*supplies*should*be*captured*by*the*chargemaster*whether*separately*payable*or*not.*Reviews*can*be*comprehensive*or*focused.*We*can*review*care*management*compliance*and*effec4veness,*ICD89*and*CPT84*code*assignment,*documenta4on*by*physician*and*ancillary*staff,*and*billing/charges.

Audit)Focus)Areas* ●***Coding:**Professional,*Technical,*Modifiers,*E/M*levels

* ●***Billing*and*Claims:**Correct*reflec4on*of*services,*Properly*bundled

* ●***Chargemaster:**Descrip4on,*Revenue*codes,*CPT*and*HCPCS*charges

* ●***Documenta4on:**Complete,*Legible,*Time*repor4ng

* ●***Care*paths:**Documented,*Adherence

* ●***Proper*billing*for*level*of*care*(emergent,*urgent,*clinic)

* ●***Proper*billing*for*Non8physician*Providers

PHYSICIAN-BASED

Codebusters*provides*services*to*physician8based*facili4es*in*both*small*and*large*groups,*independent*

physician*associa4ons*(IPAs),*ambulatory*service*centers*(ASCs),*and*mul48specialty*organiza4ons*with*coding*and*audi4ng*services.*We*work*closely*with*you*to*understand*your*unique*rela4onship*to*

payers*and*affiliates*to*iden4fy*poten4al*compliance*risks.*Our*professionals*have*experience*across*

the*professional*services*coding*and*billing*spectrum.*Coding*and*audi4ng*can*be*performed*onsite*or*

remotely.*We*can*provide*training*to*your*staff*both*onsite*and*via*video*chat.

*Codebusters*professional*services*coders*have*exper4se*across*a*broad*range*of*special4es.**We*work*

closely*with*our*clients*to*ensure*that*they*understand*the*documenta4on*requirements*for*billing*

their*specific*prac4ces,*and*capturing*all*appropriate*charges.

Prac..oner)Reimbursement)ChallengesThe*compliance*issues*surrounding*billing*within*different*sites*of*service*and*physician*arrangements*

can*be*quite*complex.*Addi4onally,*evalua4on*and*management*(EM)*coding*requirements*vary*within*

medical*special4es,*especially*as*it*relates*to*medical*decision*making,*crea4ng*the*need*for*coders*

with*direct*experience*in*a*given*prac4ce*specialty.*Our*medical*coders*possess*strong*knowledge*of*

surgical*and*EM*CPT*coding,*modifier*usage,*and*ICD89*coding*as*it*relates*to*medical*necessity*requirements.*Codebusters’*coding*staff*is*well*versed*with*physician*payment*systems,*such*as*RBRVS*

and*the*included*Medicare*global*surgery*package*(GSP).

*

Physicians*working*out*of*clinics*ohen*maintain*mul4ple*rela4onships,*i.e.,*being*based*out*of*a*clinic,*

but*working*at*a*number*of*hospitals*or*specialty*clinics.*Establishing*strong*informa4on*flow*mechanisms*between*the*site*of*service*and*the*medical*clinic*are*crucial*to*appropriate*access*to*

documenta4on*for*coding*and*billing.

Compliance)AuditsCodebusters*approaches*each*professional*services*audit*with*the*customer’s*needs*at*the*forefront.*

Auditors*can*perform*the*audits*and*training*feedback*on8site*or*remotely.*We*help*physicians*and*

non8physician*prac44oners*(NPPs),*such*as*nurse*prac44oners*and*physician*assistants*8*whether*

independent*or*part*of*a*larger*group,*IPA,*or*hospital*chain*8*abide*by*complex*coding*and*billing*

guidelines*so*that*they*receive*full*compensa4on.*Each*audit*is*designed*around*clearly*defined*parameters*and*exis4ng*compliance*efforts.*As*part*of*the*planning*stage*we*consider*current*and*past*

compliance*ini4a4ves,*the*highest*areas*of*risk,*and*budgetary*restric4ons.

The*compliance*concerns*for*physician*coding*and*billing*depend*largely*on*the*site*of*service*and*the*prac4ce*specialty.*Primary*areas*of*focus*are*proper*diagnosis*coding,*establishing*the*medical*necessity*of*procedures*performed*and*the*evalua4on*and*management*(E/M)*level,*along*with*the*appropriate*qualifying*modifiers.*E/M*codes*should*be*validated*against*the*documenta4on*to*support*the*level*of*service*provided*by*the*physician*or*non8physician*prac44oner.*

The*applica4on*of*1995*or*1997*Evalua4on*and*Management*Documenta4on*Guidelines*must*also*be*reviewed*for*consistency*and*financial*effec4veness.*Special*focus*should*be*spent*on*E/M*codes*for*day8of8discharge*management*services,*consulta4ons,*cri4cal*care*services,*psychotherapy,*and*individual*psychiatric*tes4ng*for*inpa4ents.*The*OIG*has*long*inves4gated*the*use*of*E/M*codes*by*physicians,*typically*looking*for*aberrant*pa]erns*skewed*toward*high*volumes*of*high*service*levels.*Consulta4on*coding*is*also*a*major*area*of*focus*by*the*OIG.*For*physicians*at*teaching*hospitals,*documenta4on*should*be*evaluated*to*verify*that*it*supports*the*supervision*of*residents.

Reimbursement)Reviews* ●***E/M*level*coding

* ●***Frequency*of*E/M*levels*rela4ve*to*benchmark*for*specialty

* ●***Proper*documenta4on*rela4ve*to*coding*and*billing*for*consulta4on*services

* ●***Preven4ve*medicine*codes*versus*use*of*regular*therapeu4c*office*visit*codes

* ●***Coding*of*all*applicable*services*and*diagnoses* ●***Correla4on*of*diagnosis*codes*to*procedures*based*on*medical*necessity*guidelines

* ●***Use*of*waivers*for*services*that*the*payer*deems*not*medically*necessary

* ●***Modifiers*854*and*855*for*Medicare’s*GSP

* ●***Modifiers*876*and*877*repeat*procedures

* ●***Modifier*825*when*billing*both*E/M*level*and*surgical*procedure

* ●***NPP*coding*and*billing*for*incident8to*services* ●***Review*of*supervisory*status*(direct*vs*indirect)*for*billing*rela4ve*to*NPPs* ●***Documenta4on*of*case*management*services*that*rely*on*accurate*repor4ng*4me

* ●***Complete*and*proper*documenta4on*and*coding*for*services*provided*outside*of*clinic

* ●***Checking*for*incidence*of*poten4ally*bundled*codes*and*the*proper*use*of*859*modifier** rela4ve*to*CMS’s*CCI

* ●***Accuracy*of*claim*forms*rela4ve*to*full*inclusion*of*diagnosis*codes*and*all*procedure*codes*

Understanding*the*complex*nature*of*physician*rela4onships*and*contractual*agreements*is*cri4cal*to*apply*the*appropriate*coding*and*billing*systems.*The*Codebusters’*audit*teams*help*prac44oners*alleviate*the*uncertainty*with*regard*to*proper*Medicare*and*other*payer*billing,*through*stopping*pa]erns*of*errors,*documenta4on*training,*work*flow*analysis,*and*proac4ve*audi4ng.

INTERVENTIONAL RADIOLOGY CODING

Codebusters*performs*interven4onal*radiology*coding*and*audi4ng*services*on8site*or*remotely.*Our*consultants*have*the*exper4se*needed*to*accurately*assign*codes*and*provide*feedback*on*documenta4on*guidelines.*Auditors*review*documenta4on*of*vascular*access*site,*vessels*catheterized*and*injected,*and*complica4ons.*Aher*the*results*of*the*review*are*compiled,*an*educa4onal*in8service*is*provided*to*physicians*and*coding*staff.*The*training*can*be*provided*on8site*or*through*phone*or*video*conferencing.*Interven4onal*radiology*(IR),*neuro8interven4onal,*and*endovascular*surgery*are*some*of*the*most*complex*clinical*special4es*to*code.*This*segment*of*medicine*con4nues*to*grow*at*a*fast*pace*and*provides*significant*market*opportuni4es*for*providers.*The*expense*of*the*equipment*and*professionals*who*use*it*necessitates*that*facili4es*capture*every*dollar*of*reimbursement.*Due*to*the*complex*nature*of*the*coding*guidelines*for*these*procedures,*facili4es*have*difficulty*a]rac4ng*and*retaining*the*necessary*coding*talent.*Ohen*the*job*is*pushed*off*to*diagnos4c*radiology*coders,*technicians,*or*even*the*physician,*none*of*whom*are*ideal*candidates.**Diagnos4c*coders*may*lack*the*anatomy*and*physiology*background*to*decipher*the*myriad*of*procedures:**abla4ons,*chemo8emboliza4on,*thrombolysis,*balloon*occlusions,*kyphoplasty,*placement*of*vascular*filters,*and*other*gastrointes4nal*(GI),*neurosurgical,*and*gynecologic*procedures.Diagnos4c*coders*and*technicians*also*may*not*fully*comprehend*the*specific*coding*rules*and*edits*that*apply*to*IR*coding*and*billing.*Therefore,*much*of*the*coding*rests*on*the*shoulders*of*highly*paid*providers*who*may*not*have*the*4me*or*inclina4on*to*properly*code.*Without*professional*IR*coders,*facili4es*may*be*incorrectly*submiRng*claims*which*can*result*in*severe*under8billing*or*trigger*the*a]en4on*of*the*OIG*or*RAC*auditors.

HCC CODING

Codebusters*manages*the*en4re*cycle*of*HCC*(hierarchical*condi4on*category)*code*assignment*and*documenta4on*training,*providing*Medicare*Advantage*plans*the*informa4on*they*need*to*adequately*quan4fy*risk*and*plan*for*the*future.*Our*team*of*experienced*professionals*iden4fies*risk*areas,*calculates*financial*impact,*and*engages*in*thorough*cost*analysis*to*jus4fy*business*intelligence *strategies.*The*process*of*data*retrieval,*analysis,*and*communica4ng*documenta4on*and*coding*methods*to*physicians,*requires*careful*planning*and*experience.*Managed*care*organiza4ons*find*that*they*can*reduce*their*opera4ng*expenses*by*turning*to*Codebusters*for*the*management*and*execu4on*of*the*systems*necessary*to*fully*capture*the*ICD89*codes*that*determine*HCC*assignment.*There*are*four*main*elements*that*comprise*the*HCC*coding*cycle*as*outlined*below.*Each*demands*its *own*logis4cal*considera4ons*and*skill*set*to*perform.*We*achieve*cost*savings*throughout*each*part*of*the*cycle*by*understanding*every*aspect*of*the*necessary*inputs*and*carefully*planning*and*coordina4ng*their*implementa4on.

Engagement)PlanningWe*help*our*clients*quan4fy*the*value*of*diagnos4c,*procedural,*and*quality*indica4ons,*then*calculate*the*resource*costs*necessary*to*collect*the*data.*The*records*selected*for*review*are*a*func4on*of*the*benefit*they*return*to*an*organiza4on*and*the*costs*of*extrac4on*or*valida4on.*Understanding*the*marginal*contribu4on*the*data*set*elements*provide*offers*assurance*that*return*on*investment*is*op4mized.*The*process*starts*with*defining*the*client’s*informa4on*needs*based*on*stated*objec4ves.*We*then*begin*asking*the*right*ques4ons*of*the*data;*for*example,*in*what*pa4ent*and*provider*popula4ons*do*coding*omissions*or*errors*materially*affect*reimbursement*and*also*leave*the*organiza4on*vulnerable*to*government*compliance*viola4ons.*Providers*and*Managed*Care*Plans*must*play*offense*(in*terms*of*taking*aggressive*stand*on*accurate*documenta4on*and*coding)*to*maximize*reimbursement*based*on*the*risk*of*the*pa4ent*popula4on.*However,*defense*(in*terms*of*audi4ng)*has*become*cri4cal*since*CMS*began*random*Risk*Adjustment*Data*Valida4on*(RADV)*audits.*Risk*Adjustment*Factors*(RAFs)*that*determine*payment*from*CMS*must*be*supported*by*documenta4on*in*the*medical*record.

Data)RetrievalRecords*may*be*in*an*electronic*format,*scanned*images,*par4ally*scanned,*or*paper.*The*target*documents*need*to*be*iden4fied*and*the*permission*protocols*established*(on8site*versus*off8site*audit).*The*records*can*either*be*uploaded*to*a*secure*environment*where*coders*and*other*analysts*can*easily*navigate*to*relevant*sec4ons*or*coders*can*access*the*record*at*the*provider’s*office.*

The*provider’s*internal*prac4ces*and*office*layout,*as*well*as*the*number*of*records*to*be*audited*at*a *given*site,*will*dictate*the*most*expedi4ous*and*cost*effec4ve*solu4on.*If*records*are*in*a*paper**format*the*costs,*4ming,*and*limita4ons*of*the*individual*physician*prac4ce*dictate*whether*we*will*scan*the*records*or*have*then*transmi]ed*via*secure*fax.*Our*onsite*conduct*ensures*minimum*disrup4on*to*the*provider’s*workflow.

Audi.ngCoders*determine*the*correctness*or*absence*of*diagnos4c*codes.*The*documenta4on*which*jus4fies*code*selec4on*is*evaluated*to*clarify*if*it*meets*compliance*standards.*The*documenta4on*needs*to*support*the*diagnosis*codes*which*are*changed*or*added*in*order*to*stand*up*to*an*audit*and*create*a*repeatable*system*for*doctors*to*follow.*U4liza4on*management*professionals*examine*whether*prescribed*treatment*pathways*were*followed*and*help*iden4fy*successful*protocols.*Detailed*informa4on*about*a*pa4ent’s*condi4on*and*response*to*treatment*over4me*illuminates*best*prac4ce*treatment*protocols*and*risk*modeling*methods*to*quan4fy*future*revenues*and*expenses.

Error)Preven.on)StrategiesOur*auditors*understand*physician*produc4on*environments.*We*can*help*providers*comply*with*Medicare*Advantage*plan*documenta4on*requirements*without*significant*impact*to*their*produc4vity.*Clinicians*need*concise,*clinically*relevant*feedback*that*they*can*easily*implement*and*remember.*Coding*guidelines*can*be*referenced*for*inclusion*into*the*compliance*program.

Outline)of)Services:********●***Individualized*training*based*on*audit*findings*for*physicians*and*their*staff,*onsite*or*remote

********●***Iden4fica4on*and*solu4ons*to*systemic*barriers*to*proper*documenta4on

********●***Prac4ce*management*consul4ng*to*ensure*consistent/dependable*communica4on*flow*between** provider*and*payer

********●***Medical*group*documenta4on*training*from*concepts*to*specifics

********●***Supplement*Compliance*Program*guidelines*to*reflect*audit*findings*and*industry*best*prac4ces

********●***Pre8bill*monitoring*and*shortened*audit*intervals*enhance*reliance

Primary*Care*Physicians*(PCP)*serve*a*cri4cal*role*in*determining*a*pa4ent*treatment*path*and*ul4mate*use*of*services*(u4liza4on*management).**Most*of*a*pa4ent’s*experience*and*interface*with*the*health*plan*is*via*their*PCP.*Likewise,*much*of*a*PCP’s*interac4on*with*the*health*plan*occurs*via*the*audi4ng*and*training*process.*Plans*who*form*a*collabora4ve*rela4onship*with*PCPs*will*experience*posi4ve*pa4ent*feedback.*Thus,*pa4ent*will*be*more*likely*to*stay*in*a*given*MA*plan.

CANCER REGISTRY

Today’s*evidence*based*medicine*demands*skilled*cancer*registrars*who*can*work*with*facility,*central,*

and*special*purpose*registries.*Organiza4ons*demand*accurate*and*4mely*data,*as*informa4on*

increasingly*impacts*cancer*control*efforts.*Our*staff*of*Cer4fied*Tumor*Registrars*(CTRs)*possess*

management*and*administra4ve*skills,*extensive*knowledge*of*disease*processes,*programming*and*

database*management*experience,*and*database*analysis*competencies.*The*registrars*can*

immediately*step*in*to*support*the*healthcare*leadership*team,*providing*benchmarking*services,*

monitoring*quality*of*care*and*clinical*prac4ce*guidelines,*assessing*pa]erns*of*care*and*referrals,*

monitoring*adverse*outcomes*including*mortality*and*co8morbidity,*and*assis4ng*in*the*development*

of*registry*management*and*program*standards.

Services*******●***Onsite*or*Remote*Abstrac4ng

*******●***Follow8up*Pa4ent*Monitoring

*******●***Case*Ascertainment

*******●***State*Repor4ng*******●***Collabora4ve*and*AJCC*Staging*******●***Annual*Report*Prepara4on*******●***Quality*Assurance*Audits*(ACoS,*NAACCR)

REVENUE CYCLE

A*properly*func4oning*revenue*cycle*gets*the*money*you*have*earned*as*a*provider*of*healthcare*from*third*party*payers,*on*4me,*with*no*hassles.*The*process*of*collec4ng*money*for*services*rendered*involves*many*steps,*each*of*which*has*there*own*pinalls.*The*revenue*cycle*encompasses*many*different*systems*within*a*health*care*system.*Codebusters*brings*revenue*cycle*experts*who*can*dehly*handle*the*day*to*day*challenges*of*naviga4ng*the*health*care*reimbursement*system.

Claim)Cycle)ProcessIt*begins*with*the*pa4ent.*Each*pa4ent’s*ability*to*pay*must*be*assessed*prior*to*the*provision*services.*This*is*of*course*not*always*possible,*nor*is*it*always*possible*to*deny*care*due*to*inability*to*pay.*Once*a*diagnosis*is*determined,*the*physician*must*ensure*that*the*procedures*and*tests*required*are*jus4fied*by*the*hospital*care*management*rules*and*the*payer*guidelines.**Of*course,*the*physician*documenta4on*needs*to*be*able*to*clearly*explain*why*a*pa4ent*sought*treatment,*and*what*reimbursable*services*were*provided.*From*here*the*coders*assign*the*diagnosis*and*procedure*codes.*Codebusters’*CDI*Specialists*help*get*the*documenta4on*straight.*Other*codes*are*assigned*to*the*claim*by*the*computer*system*through*the*Chargemaster,*which*needs*annual*review.*Once*the*pa4ent*has*been*discharged,*the*claim*is*then*submi]ed*by*the*billing*department*to*the*payer,*who*verifies*that*the*claim*meets*the*specific*requirements.*Of*course,*providers*need*a*denial*management*process*in*case*a*claim*is*not*paid*correctly.*Codebusters*can*help*provide*the*personnel*who*know*how*to*manage*the*complexi4es*of*the*revenue*cycle.

CLAIM REVIEW

Codebusters*medical*records*audi4ng*services*encompass*four*cri4cal*areas:

* ●**Documenta4on*completeness

* ●**Medical*coding

* ●**Billing*compliance

* ●**Medical*necessityClients*we*help*include*acute*care*hospitals,*specialty*hospitals,*ASCs,*HMOs,*physician*clinics,*CAHs,*RHCs,*LTC,*home*health,*and*payers.

Why)do)a)claim)review?In*this*era*of*increased*scru4ny,*provider*organiza4ons*must*insure*that*their*coded*data*contains*few,*if*any*material*errors.*The*en4re*health*system*depends*on*accurate*medical*record*data*for*pricing,*research,*quality*of*care*measurement,*and*public*health*planning.*Now*that*Medicare’s*RAC*auditors*can*recoup*payments*based*on*undiscovered*coding*errors,*going*back*several*years,*providers*must*be*quick*to*iden4fy*errors*to*halt*further*financial*risk.*Without*performing*annual*external*audits*(recommended*by*the*OIG)*and*having*a*monitoring*system*in*place,*organiza4ons*may*be*unknowingly*puRng*themselves*at*tremendous*risk*of*both*under8billing*and*over8billing.*Given*the*razor*thin*margins*of*payer*reimbursement,*consistent*under8billing*could*eventually*lead*to*insolvency.*On*the*other*hand,*with*the*ever*increasing*scru4ny*from*payers,*any*benefits*of*over8billing*could*be*completely*washed*away*and*poten4al*added*penal4es.*Therefore,*it*is*incumbent*on*providers*to*diligently*analyze*their*claims*for*errors.**Codebusters*can*provide*an*audit*that*meets*your*budget*while*clearly*iden4fying*the*risk.

How)We)HelpCodebusters*auditors*possess*the*skills*and*experience*necessary*to*help*our*clients*properly*design*and*execute*highly*technical*coding*reviews.*We*work*closely*with*HIM*and*revenue*cycle*managers*to*plan*the*audit*scope*and*the*service*areas*to*be*examined.*Through*our*ini4al*site*interviews*we*come*to*a*clear*understanding*of*the*coding*and*billing*processes,*current*monitoring*ac4vi4es,*and*past*audit*results.*The*data*we*gather*in*the*inves4ga4on*step*helps*to*clarify*the*objec4ves*of*the*audit*and*the*method*with*which*to*achieve*them.*Reviews*can*extend*to*an*analysis*of*documenta4on,*coding,*claims,*statements,*and*reimbursement;*or*they*can*be*focused*on*specific*aspects*of*coding*compliance*for*various*payers.*Because*of*the*unique*nature*of*each*healthcare*facility,*we*take*a*measured*approach*to*establishing*the*size*and*scope*of*the*audit.

DRG ANALYSIS

Preven.on)is)the)Best)MedicinePreven4on*of*nega4ve*findings*by*RAC*or*other*CMS*payment*monitoring*agencies*requires*

monitoring*the*DRGs*that*these*agencies*have*targeted*in*current*and*past*claims*within*the*look*

back*period.*Codebusters*expert*medical*coders*and*auditors*help*you*iden4fy*areas*most*out*of*

compliance.

*Typically*records*will*be*requested*based*on*the*fact*that*the*assigned*DRG*has*a*much*greater*

frequency*for*that*hospital*than*other*similar*facili4es*in*the*US*and*region.*Examining*the*rela4ve*

frequencies*of*all*DRGs*and*comparing*them*to*various*benchmarks*will*allow*the*facility*to*

concentrate*limited*audit*resources*on*areas*that*are*most*likely*to*either*contain*errors,*or*at*a*

minimum*represent*a*heightened*risk*area*for*external*audit.*By*focusing*on*subsets*of*DRG*frequency,*such*as*CC*and*MCC*ra4os,*or*rela4onships*between*DRGs*that*are*linked*by*similar*

diagnosis*or*procedure*codes,*a*facility*can*see*if*they*deviate*from*na4onal*or*regional*averages,*

thereby*gaining*insight*as*to*direc4ng*their*own*audit*efforts.*Codebusters*can*help*you*analyze*your*

data*to*iden4fy*audit*hotspots.

Highlight)Trouble)SpotsDetec4on*of*under8coding*can*also*be*informed*by*DRG*frequency*analysis.*Because*all*inpa4ent*

CMS*admissions*must*be*mapped*to*one*and*only*one*DRG,*a*change*in*a*one*DRG*will*result*in*a*

change*in*another.*A*histogram*showing*each*DRG*on*the*horizontal*axis*and*the*frequency*on*the*

ver4cal*axis,*lends*itself*to*both*variance*analysis*and*reimbursement*details.*DRGs*that*contain*a*

high*frequency*will*represent*a*poten4al*risk*area*if*the*depending*on*the*error*rate*in*a*par4cular*DRG,*likewise*for*highly*weighted*DRGs.

*

A*properly*designed*coding*audit*can*iden4fy*various*types*of*coding*errors,*making*general*

statements*about*frequency.*The*materiality*of*those*errors*is*a*func4on*of*both*the*frequency*or*

volume,*and*the*dollar*amount*of*the*given*error.*Areas*of*high*risk*would*be*those*DRGs*that*account*for*a*larger*than*average*amount*of*revenue.*Because*only*a*limited*number*of*records*can*

be*audited,*it*is*necessary*to*devise*an*audit*strategy*that*allows*the*auditor*to*focus*on*those*areas*

of*highest*or*material*risk.*Records*with*the*highest*DRGs*should*be*constantly*monitored*to*ensure *

their*correctness,*as*this*is*where*external*auditors*focus*their*efforts*and*where*the*facility*could*

lose*the*most*money.

CHARGEMASTER

The*charge*descrip4on*master*(CDM)*is*the*founda4on*of*the*revenue*cycle.*It*must*be*constantly*maintained*to*keep*pace*with*changes*to*coding*guidelines*and*payer*policies,*like*ICD810.*Codebusters’*review*services*iden4fy*mapping*errors*that*cause*underbilling,*overbilling,*or*compliance*deficiencies.*The*purposes*of*the*review*are*fewer*denials*and*correc4ons,*which*result*in*reimbursement*at*full*contract*value.*Our*CDM*review*services*help*ensure*that*all*charges*posted*to*the*pa4ent’s*account*were*documented*and*entered*at*the*4me*of*order*and*that*the*services*and*supplies*were*actually*supplied.*The*chargemaster*is*the*way*hospitals*capture*usage*of*supplies*and*rou4ne*services*without*requiring*medical*coders*to*interpret*documenta4on.*The*level*of*automa4on*varies*among*facili4es,*with*many*in*a*state*of*transi4on*toward*greater*automa4on*through*integra4on*with*an*EHR.*The*more*transac4ons*that*the*CDM*records*the*more*crucial*it*is*to*capture*services*and*supplies*and*ensure*they*map*to*correct*revenue*codes,*HCPCS*codes,*and*payer*charges.*Providers*must*constantly*maintain*chargemasters*to*stay*abreast*of*the*numerous*coding*changes*and*payer*requirements.*A*majority*of*a*facility’s*revenue*is*generated*as*a*result*of*charges*entered*or*triggered*by*department*personnel.*Given*that*the*chargemaster*is*a*largely*automated*process*where*correctness*is*not*evaluated*by*HCPCS*coding*specialists*at*the*point*of*entry,*facili4es*can*experience*repea4ng*errors*that*if*not*caught*could*result*in*massive*underbilling*or*fines*and*penal4es*for*overbilling.*A*significant*benefit*of*an*accurate*CDM*is*that*it*can*prevent*RAC*automated*review*findings,*ensuring*revenue*collected*will*be*kept.

●******Examine*the*mapping*between*revenue,*CPT*and*HCPCS*codes

●******Evaluate*department*policies*and*prac4ces*for*charge*entry

●******Iden4fy*services*performed*but*not*recorded

●******Align*charge*4ckets*with*CDM●******Review*denied*claims*for*CDM*discrepancies

●******Develop*hospital8wide*E/M*coding*policies

●******Address*pa4ent*status*indicators*(admission*orders*for*outpa4ent,*observa4on,*and*

inpa4ent)

●******Educate*department*staff*on*per4nent*coding*issue

PROJECT MANAGEMENT

Finding*the*right*people*to*lead*your*organiza4on*can*be*one*of*the*most*delicate*and*difficult*

decisions*an*organiza4on*must*make.*You*need*to*find*the*right*blend*of*experience*and*leadership*

style*that*works*well*within*the*organiza4on*as*it*is*now*and*as*it*changes.*The*next*several*years*will*

con4nue*to*test*HIM*departments*as*they*work*to*incorporate*changes*to*EHR*technology*and*

regula4ons,*and*implementa4on*of*a*completely*new*code*set*in*ICD810.*Health*care*is*moving*fiercely*

into*the*future.*Facili4es*need*HIM*Directors*and*Project*Managers*who*can*lead*change*efforts*as*

well*as*implement*exis4ng*policy*and*iden4fy*compliance*risks.

Health)Informa.on)Technology)J)HITCodebusters’*HIT*is*commi]ed*to*helping*healthcare*facili4es*get*the*most*out*of*their*EHR*so*they*

achieve*benefits*that*are*most*meaningful*to*them*and*their*pa4ents.*We*can*help*get*the*staff*you*

need*to*build*a*fully*integrated*and*connected*enterprise*wide*EHR.*We*connect*pa4ents*to*clinicians,*

who*are*connected*to*HIM,*who*are*fully*interfaced*with*the*revenue*cycle,*who*are*all*checked*by*

compliance,*and*overseen*by*management.

*

Building*an*EHR*occurs*in*many*stages*with*many*different*types*of*professionals.*We*can*help*you*find*

the*people*to*bring*your*EHR*to*life.*We*want*the*achievement*of*meaningful*use*to*yield*be]er*health*

outcomes,*cost*efficiency,*and*opera4ng*control.

*

Our*account*managers*will*work*closely*with*your*hiring*managers*to*deliver*the*professional*with*the*

exact*skills*your*IT*team*needs,*from*programmers*to*program*coordinators.*We*do*a*lot*of*work*to*

understand*the*culture*of*your*work*environment*and*the*end*product*you*need*from*the*posi4on.

ICD-10The$transi+on$to$ICD010$from$the$current$code$set$of$ICD09$affects$virtually$every$aspect$of$healthcare $opera+ons.$Every$organiza+on,$whether$they$are$a$large$community$based$hospital,$physician$clinic,$health$plan,$or$regulatory$ins+tu+on,$must$make$major$adjustments$to$prepare$the$way$their$data$on$health$encounters$will$be$reported.$Unques+onably$this$represents$the$greatest$moment$of$change$to$the$US$health$care$system$in$a$genera+on,$but$comes$at$a$+me$of$two$other$fundamental$changes,$the$Affordable$Care$Act$and$transi+on$to$next$genera+on$EHRs.$These$tectonic$shiNs$are$puOng$serious$burdens$on$health$informa+on$departments.$For$example,$it$is$es+mated$that$coding$produc+vity$could$drop$between$15045%$depending$on$a$provider’s$case$mix$and$preparedness.

At$Codebusters$we$are$passionate$about$helping$providers$make$sure$they$are$able$to$capture$and$report$clean$data$on$their$pa+ent$encounters$to$payers$and$regulatory$agencies,$both$of$which$need$to$be$certain$that$the$data$is$complete$and$uncorrupted.$If$providers$have$compliant$physician$documenta+on$and$the$medical$coding$staff$handle$the$volume$of$records,$then$clean$data$should$be$produced.$Codebusters$is$commiUed$to$delivering$the$documenta+on$specialists,$coders,$and$auditors $who$have$the$exper+se$to$lead$our$clients$to$ICD010$utopia.$What$follows$is$an$overview$of$ICD010,$its$impacts,$and$how$Codebusters$empowers$its$clients$to$not$miss$a$beat$when$it$comes$to$successfully$managing$the$transi+on.

About ICD-10ICD$stands$for$Interna+onal$Classifica+on$of$Disease.$It$is$a$system$developed$by$the$WHO$for$classifying$health$condi+ons$(diagnoses)$and$treatments$(procedures).$Essen+ally,$it$allows$us$to$understand$why$people$are$seeking$health$care,$and$generally$the$results$of$the$treatment$we$provide.$The$codes$allow$us$to$do$research,$like$understanding$public$health$trends,$and$also$to$help$determine$how$to$pay$for$health$care$encounters.$Insurance$companies$typically$use$the$reported$diagnosis$codes$to$evaluate$if$the$procedures$administered$were$medically$necessary,$thereby$jus+fying$reimbursement.

BackgroundIn$the$United$States$we$use$a$unique$version$that$generally$has$more$medical$codes$than$any$other$country,$known$by$the$suffix$CM,$which$stands$for$clinical$modifica+on.$Since$1979$we$have$used$ICD090CM,$the$ninth$revision$of$ICD.$Most$of$the$rest$of$the$world$has$been$using$ICD010$since$the$early$1990s.$Each$new$revision$looks$to$organize$diagnoses$and$procedures$that$reflects$modern$medical$knowledge.$ICD09$diagnosis$codes$are$used$to$describe$all$diagnoses,$regardless$of$pa+ent$seOng$0$and$beginning$on$October$1,$2014$ICD010$codes$will$be$mandatory$for$covered$en++es$under$HIPAA$(worker’s$compensa+on$and$auto$insurance$companies$are$not$covered$en++es$and$may$choose$to$not$implement$ICD010$coding).$

ICD-9 to ICD-10ICD010$represents$a$major$change$from$ICD09$in$terms$of$its$sophis+ca+on$and$clarity,$reflec+ng$how$medicine$has$changed$and$evolved$over$the$past$30$years.$Many$new$condi+ons$have$been$discovered$and$old$ones$beUer$understood,$and$many$new$treatments$and$medical$devices$developed$since$ICD09$was$implemented.$In$fact$ICD0100CM$has$68,000$diagnosis$codes$and$ICD0100PCS$has$74,000$procedure$codes.$Compare$that$to$ICD090CM$which$has$13,600$diagnosis$codes$and$3,000$procedure$codes.$The$diagnosis$por+on$of$ICD010$can$really$be$viewed$as$an$evolu+on$of$ICD09$since$most$of$the$structure$is$similar.$However,$procedure$coding$should$be$seen$as$a$departure.$Since$ICD010$is$a$much$expanded$code$set,$this$means$that$reimbursement$is$going$to$be$far$more$accurate$and$research$on$medical$processes$and$outcomes$will$be$much$more$detailed.

How ICD-10 Impacts ProvidersDiagnosis$codes$affect$nearly$every$system$and$process$of$healthcare$organiza+ons,$from$providers$to$health$plans$and$the$agencies$to$which$they$report.$The$largest$impact$for$providers$will$be$felt$in$the$revenue$cycle,$specifically$related$to$code$assignment$that$follows$from$physician$documenta+on.$The$explosion$of$so$many$addi+onal$codes$inherently$means$that$each$code$is$far$more$specific$in$iden+fying$condi+ons$and$treatments.$As$a$rule,$codes$can$only$be$assigned$according$to$documenta+on$in$the$medical$record;$therefore,$physicians$are$now$charged$with$increasing$the$level $of$detail$they$have$been$accustomed$to$providing$for$the$past$30$years.$$In$the$absence$of$proper$informa+on,$codes$will$not$be$able$to$be$adequately$assigned,$thereby$affec+ng$the$amount$of$reimbursement$due$providers.

Coding Is The Key

Health$plans,$systems,$and$providers$large$and$small,$need$medical$coders$who$are$fluent$in$ICD010.$Your$coding$team$must$be$able$to$iden+fy$when$documenta+on$is$insufficient$to$support$the$most$accurate$code$assignment.$In$many$respects$one$has$to$view$the$medical$coder$as$the$last$line$of$defense$in$the$determina+on$of$whether$code$assignment$is$completely$accurate.$Many$items$on$the$remiUance$advice$to$the$Payer$are$hard$coded,$ie$assigned$automa+cally,$through$the$EHR.$However,$it$is$medical$coders$who$assign$the$primary$and$secondary$diagnosis$codes$in$the$outpa+ent$seOng$in$addi+on$to$procedure$codes$for$the$inpa+ent$seOng.$

Though$computer$assisted$coding$systems$are$crea+ng$some$efficiencies$in$the$coding$process,$medical$coders$do$the$heavy$liNing$when$it$comes$to$ensuring$coding$compliance,$specifically$iden+fying$if$documenta+on$is$missing$or$does$not$properly$describe$a$pa+ent’s$encounter.$The$documenta+on$must$match$word$for$word$what$the$coding$guidelines$dictate.$Accurate$coding$is$cri+cal$from$both$a$reimbursement$and$compliance$perspec+ve.$If$the$medical$coder$does$not$catch$an$error$in$documenta+on,$and$results$in$an$incorrect$code,$the$problem$is$perhaps$unlikely$to$be$caught$by$the$claim$scrubber$(the$soNware$designed$to$iden+fy$codes$that$should$not$be$reported$together$or$are$highly$unlikely)$employed$by$both$the$providers$and$the$recipients$of$the$data,$payers$and$repor+ng$bureaus$for$example.$Thus,$the$coders$are$in$many$respects$the$first$and$last$line$of$defense$against$repor+ng$errors.

Each$of$our$coders$is$given$specific$training$for$the$clients$we$serve.$They$are$given$a$crosswalk$for$all$of$the$most$common$cases$they$code,$and$will$be$audited$to$ensure$they$have$a$complete$understanding$of$ICD010$and$how$the$documenta+on$requirements$may$differ$from$ICD09.

by$Vincent$Kobayashi

How Codebusters Can HelpCodebusters$is$a$team$of$health$informa+on$specialists$dedicated$to$helping$our$clients$seamlessly$

transi+on$to$ICD010.$We$bleed$medical$coding$compliance.$We$have$made$a$firm$commitment$to$

ICD010$coding$training.$We$have$developed$an$online$ICD010$course$covering$inpa+ent$diagnosis$and$

procedure$coding$in$depth.$An$online$outpa+ent$ICD010$diagnosis$coding$course$will$cover$cases$

common$to$the$hospital$based$seOng.$We$have$also$wriUen$a$book$covering$case$studies$in$the$

emergency$room$seOng$that$walks$coders$through$the$mechanics$of$ICD010$diagnosis$coding.$

Beginning$in$2013$all$coders$will$be$required$to$pass$ICD010$pre0employment$tests.