Clinical Coding

CBIZ Clinical Coding services help providers enhance their revenues through a blend of clinical and financial expertise. Our clinical team possesses extensive knowledge of the entire reimbursement cycle, including the charge, coding, billing and reimbursement components for Medicare and Medicaid, as well as many managed care payers.

Common engagements include:

ICD-10 Services

We draw from proprietary analytics and more than 30 years of coding expertise to conduct in-depth review of your ICD-10 coding and determine where processes could be improved or streamlined. Our I-10 Check solution differs from other coding evaluations in a number of ways.

Charge Description Master Review

In today’s competitive healthcare market, providers are under increasing pressure to net every dollar possible. Hospitals can no longer prosper without paying close attention to every aspect of capturing revenue, including the Charge Description Master (CDM). CBIZ's CDM/CPT-4 Review analyzes the CDM document to ensure that the current coding practices are up-to-date and all provided services are included.  Additionally, CBIZ works with management to identify existing compliance problems and inefficiencies in the charge to reimbursement cycle. The scope of the review can be limited to selected departments or encompass the CDM for the entire facility. Important capabilities include:

  • Review of each of the existing charge items for CPT and UB revenue code assignment, which verifies that the most current codes are used for billing purposes and that the appropriate codes are assigned.
  • Current listings are reviewed for appropriate charging procedures to determine if the facility has the appropriate codes set up to yield complete reimbursement.
  • Findings and revisions are reviewed with the department's/facility's clinical management and follow-up is performed to ensure that all revisions are incorporated into the CDM and all chargeable items are captured.
  • Development and review of APC-based charge master to ensure the facility receives appropriate reimbursement for outpatient procedures.

The CDM/CPT-4 Review can yield significant financial returns. The review can also produce considerable intangible benefits, including:

  • The appropriate capture of all chargeable items, producing better audit trails and improved cost management, which may lead to improved reimbursement
  • Analysis of charging and billing processes and identification of issues that lead to denied claims or inefficient charge capture
  • Updated CDMs containing the most current services being provided
  • Identification of non-compliant practices

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CDM Monitor

CBIZ has fused its proprietary computerized CDM review software with its professional hands-on consulting services to create a new automated CDM review and maintenance product that allows providers to maintain a quality CDM in both a timely and cost effective manner.

The key to the CDM Monitor service is the human element, which other strictly “computerized” approaches lack. Our service includes analyses and reviews by clinical staff, ensuring a customized approach that will meet the individualized needs of each provider. The CDM Monitor will provide you with:

  • An initial automated review of the CDM to identify omitted codes, superfluous codes, coding inconsistencies and inaccurate radiology modifiers
  • Continual maintenance of the CDM to identify areas of potential coding inconsistencies through quarterly computerized reviews of the current CDM and revenue and usage report
  • Direct reporting of identified inconsistencies to management, including coding changes, additions, deletions and revisions by our clinical consulting professionals
  • Timely notification and interpretation of new developments regarding changes to coding guidelines as issued by HCFA by our clinical consultants
  • Validation of charge levels through a yearly review of the charges on the CDM to the published APC rates adjusted for the provider’s mark-up factor
  • Ongoing coding support with one of our clinical staff members onsite or via phone, e-mail or facsimile, including specific coding questions related to the CDM

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Chart to Bill Audit

The chart to bill audit entails a line-by-line analysis of coding for outpatient services to make certain that the procedure is correct and the appropriate CPT and revenue codes are assigned. The analysis includes a sampling of outpatient uniform bills, including ambulatory surgery, emergency department, cardiology, radiology, radiation oncology and infusion/chemotherapy bills. Our clinical staff will review the uniform bills and the corresponding medical record documentation.

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CDM Review for Managed Care

CBIZ will analyze a facility's CDM to determine its ability to accurately code, charge and bill according to the managed care contracts negotiated by the facility. CBIZ will review the contracts for specific provisions related to CPT and UB revenue code assignment and determine if the items on the CDM are set up in such a way as to reduce denials and ensure reimbursement from the managed care payers. In addition, CBIZ will review the contract service definitions to determine variances between contracts and ensure that the payers and the facility utilize common definitions.

If the facility has the capability, CBIZ will review the secondary coding set up in the information system to determine the appropriateness of these codes. If the facility has the secondary coding capacity but it is not in place or operational, CBIZ will work with the finance and information system departments to assist them in appropriately and effectively utilizing this function.

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CDM Consolidation

Health systems often have CDMs that vary greatly between facilities. These variations make management reporting and cost management difficult because they fail to provide a basis for true comparison between facilities. For this and many other reasons, including information system conversions, facilities often desire a consolidated CDM.

CBIZ has the expert ability to consolidate numerous CDMs into one integrated system version. Using many of the steps described in the CDM review engagement, CBIZ can simplify the management reporting, billing and charging processes across all campuses of your health system.

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Managed Care Clinical Coding Compliance Program

The current complexity of managed care contract language and terms has resulted in significant increases in technical denial levels and unwarranted reductions in payment levels for many providers. In addition, denial levels have increased as payers use “smart” software to validate charge levels and identify unrelated services through CPT and UB code comparison. The resulting impact on revenue levels for providers has been significant and, in some cases, has threatened the financial viability of providing certain medical services.

CBIZ helps providers to reduce lost revenue due to managed care denials and payment reductions by modifying managed care coding and compliance processes. Services provided include:

  • Clinical coding compliance review of existing managed care contracts to identify potential areas of revenue exposure
  • Review of selected patient accounts, based on our findings from the initial compliance review, to determine whether revenue erosion has begun and to what extent
  • Presentation to management regarding the review findings, including new programs and/or revisions to existing practices that are required to reverse the existing erosion of revenues and opportunities to recover monies from the managed care payers

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CBIZ has an experienced team of clinicians that can work with your staff to provide one-on-one coding education or structured educational programs for entire departments, the billing staff or the medical staff.

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Key Contacts
Stacy Pereira Stacy Pereira Executive Director
Jeff Lampman Jeff Lampman Executive Director