At the heart of any claim is the medical coding of diagnoses, procedures and services that determine potential DRGs and reimbursement rates. Washington & West’s coders are certified inpatient (CCS) and outpatient (CPC) coders in addition to American Health Information Management (AHIMA) Approved ICD-10-CM/PCS Trainers. Our coders keep up-to-date on the latest coding rules and guidelines, Centers for Medicare and Medicaid Services (CMS) and commercial regulations and specific targeted codes by government contractors. Our experienced, credentialed team of clinician coders is readily available to assist in inpatient coding, outpatient coding and DRG reassignments.
Precise coding ensures compliance with both commercial insurance regulations and CMS regulations. It also ensures proper reimbursement and maintains quality controls. Washington & West’s coding team takes a unique perspective to coding denials. Each record stands alone and a meticulous review of the medical record will determine the correct coding for each claim.
Inpatient Coding Denials
Because Washington & West’s coders review the majority of coding denials from a clinical standpoint, they are able to defend coding denials in all aspects of the inpatient setting. Our certified coders are also clinicians with extensive acute care experience in all areas of the inpatient setting, including critical care, medical and surgical. They are experts in coding the most complex diagnosis codes, sequencing and exclusion code denials. Weidentify patterns and trends from all categories in order to defend the hospital coding and provide specific feedback for documentation and process improvement.
Outpatient Coding Denials
Our certified coders are experts in coding evaluation and management services, emergency room, operative and procedure notes, therapies, bundling and appropriate modifiers. We have successfully defended unlisted procedure codes through a detailed analysis of a patient’s medical record and in depth explanation of the necessity of the procedure.
Payment by DRGs uses a complex formula based on the claim’s procedure and/or diagnosis codes which result in a payment process that is based not on a patient’s length of stay (a per diem rate), but on the acuteness of the patient’s presenting condition and the services rendered by the hospital. As a result of the increasing use of this billing and payment technique, there has also been a rise in frequency of DRG reassignments and DRG downcodes by the health plan. These types of denials are issued as a result of the health plan’s review of the medical records and a subsequent adjustment to the claim’s procedure and/or diagnoses codes, and ultimately the DRG. This adjustment, which is often due to what the health plan considers to be omissions in chart documentation, results in a reimbursement amount that is less than what is expected by the hospital.