Risk and Compliance Solutions
We provide independent medical chart review to align your organization with the latest regulations while protecting your financial health and reputation.
Stay Ahead of the
Compliance Curve
The ever-changing healthcare landscape of navigating the complexities of risk and compliance can feel overwhelming. Regulatory changes, audit pressures, and the need for accuracy demand your attention - increasing your burden and burnout rate.
Our expert team conducts thorough audit reviews, ensuring that your clinical documentation is accurate and fully compliant. With our clinical documentation integrity and education programs, we empower your staff to meet the required standards confidently.
We also offer specialized coding and billing education to reduce errors and enhance financial performance. Our pre-payment and post-payment review services provide an additional layer of assurance, ensuring that every claim is accurate before and after submission.
Coding vs. Auditing
Ensuring Accuracy & Compliance in Healthcare Billing
Both coding and auditing are essential for accurate billing and compliance, but they play distinct roles.
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Coding is the process of assigning standardized codes (like ICD and CPT) to patient diagnoses and procedures based on a review of their health records. Coders interpret clinical documentation and apply specific coding guidelines to accurately reflect the services provided. Their primary focus is on translating medical information into standardized codes for billing and data reporting.
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Auditing, on the other hand, is an evaluative process. Auditors review coded health records to assess the accuracy of the assigned codes and ensure compliance with regulations. They go beyond simply checking codes, also considering documentation quality and the appropriateness of coding for reimbursement. Auditors use their extensive knowledge to identify errors, provide feedback, and recommend improvements to coding processes.
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Coding is about accurately assigning the right codes, while auditing is about ensuring that those codes, and the entire coding process, are correct, compliant, and effective.
A coder does not have to be an auditor and an auditor does not have to be a coder. While both roles are connected, they have different primary responsibilities, skill sets, and objectives.
Both are vital for maintaining the financial health and regulatory integrity of healthcare practices.
Audit Readiness
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An annual audit is a systemic, critical review performed once a year to assess the quality of medical care, ensure compliance with laws and regulations, and evaluate the accuracy of documentation and billing procedures
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To identify errors or deficiencies in documentation, billing, or clinical practice, ensure regulatory compliance (such as with HIPAA or payer guidelines), and optimize the practice’s revenue cycle.
To correct errors in documentation and billing practices
To protect against external investigations, malpractice claims, and payer denials by proactively resolving potential compliance issues.
The Office of Inspector General (OIG) recommends that medical practice audits be conducted at least annually.
A typical audit examines a sample of medical records, comparing them against accepted standards or regulatory requirements to identify patterns or errors.
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Annual audit helps maintain a high standard of care, reduces risk of penalties and recoupments, and ensures the financial and legal well-being of the practice.
Provides educational opportunities for providers and staff regarding best documentation and billing practices.
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The audit involves reviewing a sample size (often 5-15 charts per provider) for compliance with coding, billing, and clinical standards, and then providing recommendations for improvement.
Findings from the audit are documented, and action plans including educational sessions are implemented to correct identified issues and improve practice performance.
A typical audit examines a sample of medical records, comparing them against accepted standards or regulatory requirements to identify patterns or errors.
Your Medical Notes Checklist
Quick daily reference for clinicians
Pulsewise Compliance Solutions
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We offer specialized services in Clinical Documentation Improvement (CDI), which focuses on enhancing the accuracy and completeness of clinical documentation to reflect the true complexity of patient care. Effective CDI not only supports improved patient outcomes by ensuring that healthcare providers have all relevant information for treatment decisions, but it also plays a crucial role in maintaining compliance with regulatory standards and optimizing the revenue cycle. By improving the quality of documentation, we help healthcare organizations achieve higher reimbursement rates, reduce audit risks, and enhance overall operational efficiency. Trust our expertise to strengthen your documentation practices, ensuring both better patient care and financial performance.
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Our pre and post-payment chart review provide comprehensive support to ensure the accuracy and compliance of your medical coding and billing practices.
In the pre-payment phase, we conduct thorough reviews of medical records and documentation to identify any discrepancies or issues before claims are submitted, helping you minimize denials and maximize revenue.
After payment, our post-payment reviews analyze medical records for compliance with coding guidelines and payer requirements, ensuring that your documentation supports the services billed.
Annual Chart Review
This proactive approach not only enhances accuracy and reduces audit risks but also contributes to a more efficient revenue cycle, allowing your organization to focus on delivering quality patient care.
Professional Disclaimer:
In the event that your organization requires an appeal based on our audit findings, we would like to clarify that we will only refer audits to our consultants for appeals if we determine that the appeals are likely to be successful based on the audit findings. One of our consultants is accredited by the Office of Inspector General (OIG) as an Independent Review Organization (IRO) and will adhere to their recommendations in conjunction with our legal counsel.
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Clinical Documentation
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