Establishing format and content of queries how to

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Establishing format and content of queries How to handle rebilling of claims Encoder issues Payer-specific reimbursement policies Chargemaster review Use of consulting firms Reasons for inclusion should include: Establishes consistency in coding Demonstrates commitment to accurate coding according to official coding guidelines Provides documentation basis for payer specific coding if contrary to official coding guidelines Identifies the importance of documentation in the coding process and mechanism (query) for clarification when necessary (Hunt 2016, 286–288) References Hunt, T. J. 2016. Clinical Documentation Improvement and Coding Compliance. Chapter 9 in Health Information Management: Concepts, Principles, and Practice , 5th ed. Oachs, P. and A. Watters, eds. Chicago: AHIMA. Further Student Reading Prophet, S. 1998. Coding compliance: practical strategies for success. Journal of AHIMA 69(1):50–61.
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Copyright ©2017 by the American Health Information Management Association. All rights reserved. 257 5.25 Fraud trend analysis Subdomain V.C.1 Identify potential abuse or fraudulent trends through data analysis Subdomain V.C.1 Determine policies and procedures to monitor abuse or fraudulent trends 1. Create one graph to illustrate the comparison of three hospitals, with the state and national percentages for the distribution of MS-DRGs 190-192 using the data below. 2. Predict how each hospital might react to analysis of this graph. MS-DRG 190 discharges Hospital X 38 Hospital Y 112 Hospital Z 89 State 8300 Nation 315400 MS-DRG 191 discharges Hospital X 23 Hospital Y 104 Hospital Z 31 State 7912 Nation 290565 MS-DRG 192 discharges Hospital X 18 Hospital Y 67 Hospital Z 17 State 2214 Nation 93214 Answer Hospital X Hospital Y Hospital Z State Nation MS-DRG 190 38 112 89 8300 315400 MS-DRG 191 23 104 31 7912 290565 MS-DRG 192 18 67 17 2214 93214 Totals 79 283 137 18426 699179 Hospital X Hospital Y Hospital Z State Nation MS-DRG 190 48% 40% 65% 45% 45% MS-DRG 191 29% 37% 23% 43% 42% MS-DRG 192 23% 23% 12% 12% 13%
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258 Compliance Copyright ©2017 by the American Health Information Management Association. All rights reserved. Answer Hospital Z’s very high MS-DRG 190 at 65 percent, compared to state and national percentages of 45 percent and 47 percent, respectively, indicates that a review should be taken to ensure that these accounts are correctly coded Hospitals X and Y should review MS-DRG 192 to look for opportunities for assignment to higher MS-DRG Further Student Reading Casto, A. B. and E. Forrestal. 2015. Principles of Healthcare Reimbursement, 5th ed. Chicago: AHIMA. Oachs, P. and A. Watters. 2016. Health Information Management: Concepts, Principles, and Practice , 5th ed. Chicago: AHIMA. Sayles, N. B. and L. Gordon. 2016. Health Information Management Technology: An Applied Approach , 5th ed. Chicago: AHIMA.
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Copyright ©2017 by the American Health Information Management Association. All rights reserved. 259 5.26 NCCI guidelines Subdomain V.B.1 Construct and maintain processes, policies, and procedures to ensure the accuracy of code data based on established guidelines An internal audit of knee arthroscopy procedures has identified the following: 29880 and 29876 are being coded together for the same knee 1.
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  • Summer '14
  • Electronic health record, American Health Information Management Association

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