ABC
Always Be Compliant.
QualCode provides integrity-driven audits that help organizations uncover compliance risk and identify revenue opportunities. We conclude all audits with an educational session to ensure your ongoing success.
Compliance Audits, the Key top proper Reimbursement Management
“Billions of Dollars of yearly loss due to non-compliance!”
Following are several types of audits we provide:
Diagnosis-Related Group (DRG) Validation
Diagnosis-related group (DRG) validation Precise DRG assignment depends on clinically-supported ICD-10 diagnosis and procedure codes, a correct principal diagnosis, accurate sequencing, and detailed clinical documentation. QualCode’s experienced and credentialed auditors validate your DRGs to ensure all conditions are captured and documented correctly and with the level of clinical specificity necessary to avoid payer scrutiny.
Ambulatory Payment Classification (APC) Validation
Correct APC assignment requires accurate CPT/HCPCS coded data, regardless of whether those codes originate from the charge description master (CDM) or whether a coder assigns them manually. QualCode’s auditors validate your hard-coded and soft-coded data so outpatient claims are grouped and paid correctly the first time, every time.
Hierarchical Condition Category (HCC) Risk Adjustment Validation
In an era of risk-adjusted payments, accurate HCC capture is paramount. HCCs drive alterative payment models, pay-for-value contracts, Medicare Advantage payments, and more. QualCode’s HCC experts validate whether your organization captures each patient’s entire risk profile and whether your clinical documentation adequately supports code assignment.
Evaluation and Management (E/M) Audits
Did a provider unknowingly upcode an E/M service due to an inflated note in the electronic health record? What about undercoding? Did the documentation support a level 3 instead of a level 2? Could the provider have billed a separately identifiable service using a modifier? QualCode’s E/M experts review your documentation to answer these and many other questions, giving you the peace of mind in knowing that the claims you submit are accurate and complete.
Coding and Billing Audits for Professional Services
Physician coding increasingly requires ICD-10-CM and HCC coding expertise in addition to an intimate knowledge of CPT and HCPCS codes relevant to each specialty. QualCode’s experienced pro-fee coders take a comprehensive approach to physician billing, helping providers capture all of the revenue to which they’re entitled.
Custom Audits
QualCode also provides clients with customized audits that address one or more of the following:
Recovery Audit Contractor (RAC) targets
Program for Evaluating Payment Patterns Electronic Report (PEPPER) outliers
Pre-payment reviews
Coding- and billing-related Office of Inspector General (OIG) targets
Facility-specific vulnerabilities identified through internal quality reviews
…and more
