Health Information Management Services
Charge Process and Chargemaster Assessments
An accurate chargemaster is critical to an organization’s reimbursement process. If a facility utilizes an inaccurate chargemaster, they may be at risk for loss of revenue and/or potential overcharging issues. PYA provides extensive chargemaster review and development services. Our chargemaster assessments consist of a review of the complete chargemaster for accuracy, completeness and appropriate usage by department. We also review and identify invalid, inaccurate or mismatched CPT/HCPCS and revenue codes. In addition, we can assist with a pricing analysis of current and potential new charges. Upon completion of the initial data review PYA will also assess and evaluate the charge entry and claims processes and facilitate the implementation of changes to the existing chargemaster and surrounding charge processes as needed.
Outpatient Prospective Payment System (OPPS) and Ambulatory Payment Classifications (APC) Assessments
APCs are the payment methodology utilized by the outpatient prospective payment system developed and implemented by CMS for the reimbursement of hospital outpatient services. Many facilities continue to struggle with the day to day management of the APC system. Changes in pass-through items, National Correct Coding Initiatives (CCI Edits), and billing requirements for specialized services make it difficult to stay abreast of changes needed internally. PYA provides organizations with the knowledge and operational support required to ensure successful management of the Ambulatory Payment Classification System. Specifically, PYA will review current outpatient utilization of those areas most commonly affected to determine the impact on the claims process and reimbursement. The existing infrastructure and data flow is also reviewed to determine what data elements and steps may require process changes in order to comply with APC payment guidelines. Financial impact analysis may also be provided with each assessment.
Standardized Chargemaster Development
The consolidation of multiple hospitals into a healthcare system has created the need for assistance in the standardization of unique, facility based chargemasters into one common consolidated charge structure. PYA can provide such services. This endeavor will allow the system to identify potential compliance related issues, identify lost charges, enhance decision support initiatives and provide a mechanism for uniform and ongoing corporate level chargemaster maintenance.
DRG Validation
PYA’s DRG validation services provide hospitals with the information needed to determine the level of accuracy with which they submit inpatient claims for reimbursement. An assessment of the medical record documentation is conducted and the information is compared to corresponding ICD-9 code assignment to ensure appropriate DRG assignment.
Inpatient/Outpatient Compliance Assessments
PYA’s inpatient/outpatient compliance assessments are intended to provide facilities with information necessary to meet Medicare and other governmental agencies' compliance guidelines. PYA closely reviews DRGs targeted by the OIG and Medicare and conducts detailed quality and coding analysis. Outpatient surgical compliance assessments are provided as well, to ensure inappropriate billing and unbundling is not occurring. Education and quarterly follow-ups are an important portion of the review as our goal is to eliminate the need for outside consulting services and reduce overall financial exposure.
Services Offered:
- Charge Process Assessments
- Chargemaster Assessments
- OPPS Assessments
- APC Assessments
- Chargemaster Development
- DRG Validation
- Inpatient/Outpatient Compliance Assessments