UB04 Audits
UB04 audits identify areas in reimbursement claims where hospitals are at risk of non-compliance, and sometimes identify opportunities of missed reimbursements. The quarterly audit includes an in-depth review of Medicare 835 remittances within a certain date range, which our staff, which includes certified coders, searches for potential coding and billing issues. The audit also includes trending for denials to assist in denials management.
What This Service Includes
The specific areas that are audited include:
- Medical necessity, claim denials, and line item rejections
- HCPCS/CPT-4 code assignment
- HCPCS/CPT-4 codes and revenue code linkage
- Appropriateness of modifier application
- Units of service
- Value and condition codes
- "Date spans"
- Non-covered codes
- Billing manipulations
- Edit validity
- Physician legibility
- Appropriateness of bill type
- Key performance indicators (See below for more information about KPI)
Additional features of this service include:
- Review and investigation of "medical necessity issues" directly related to actual documentation of physicians' order versus ICD-9 diagnosis codes submitted
- Review and investigation of "billing" edit capabilities to compare final UB04 submitted for review against billing information reflected on the 835 remittance form
- Identification of issues related to the CDM, e.g. hard coded versus dynamic coding assignments
- Review of coding competency by coding abstract
- Admission status
How You Can Benefit From This Service
The primary benefits of UB04 audits are to identify reimbursement opportunities, augment on-going compliance processes, and establish a foundation for operational improvements. We can:
- Identify areas of non-compliance, including the risk of overpayment
- Identify opportunities for reimbursement
- Improve coding and billing processes by providing benchmarking information for key performance indicators
Key Performance Indicators
Outpatient UB reviews that we perform, include the following key performance indicators (KPI):
Patient Status
Reviewed on each record to determine the appropriateness of the patient status based on documentation in the medical record, including the order, i.e., inpatient, outpatient, observation; areas of concern related to billing of observation services are also identified.
CPT/HCPCS Code Accuracy
Includes verification of CPT/HCPCS codes reflected on the outpatient claim whether assigned by coding staff or hard-coded in the chargemaster, correct Coding initiative edits, omitted codes, and appropriateness of charges based on applicable Medicare billing guidelines.
Documentation
Should be available in the medical record to support all services billed, including physician’s orders that are signed by the physician.
Denials Management
Targets claims that were denied in their entirety, and claims with line item denials related to medical necessity or issues with modifiers.
Compliance/RAC
Encompasses outpatient services currently known to be included in the RAC audits, services billed with incorrect units of service or incorrect dates of service, and other compliance related issues not addressed above.