• We provide several levels of service for improving hospitals' coding, reimbursement, compliance and effectiveness of operations in the overall documentation, coding, billing, claims filing and reimbursement process. The key issues addressed in Revenue Enhancement include:
    1. Charge Master Review With Compliance Considerations
    2. Outpatient Coding/Documentation Review
    3. Coding, Billing, Claims Processing Review
    4. Preparation For APCs/APGs Recommendations
    5. Custom designed engagements are configured to meet specific needs.


  • Charge Master Review With Compliance Considerations
    • Process & Activities. The process of a detailed study for outpatient revenue enhancement requires a number of steps:
      1. Detailed review of the overall flow of information from the point of service to receipt of reimbursement including the coding, charge development, bill generation, UB-92/HCFA-1500 generation, reimbursement monitoring, denial processing and general information flow including both manual and computer based processing.
      2. Detailed review of the computer system, the various reports available relative to outpatient coding including reports by CPT/HCPCS, productivity studies, the efficiency and effectiveness of the manual interface to the computer system for billing and claims generation, outpatient data base development capabilities and related areas. We pay particular attention to situations in which there are interface problems and response time difficulties. We then explore methods that allow computer system enhancement to assist those in the billing and claims generation process. Further, we perform a review of any encoding and/or optimization software.
      3. Coding review of 100 outpatient charts representing a wide range of coding for surgery, ancillary services and physician services as appropriate. Correlation and review of the patient chart with associated coding analyzed and related to the actual UB-92/HCFA-1500 generated by the A/R computer system. Errors are noted, and patterns relative to coding and/or charging are analyzed.
      4. Detailed review of the Charge Master on a line item basis by department. The following items are reviewed.
        • Service Item Description,
        • CPT/HCPCS Code,
        • Revenue Code,
        • Accounting Code,
        • Charges
        • Overall organization of the Charge Master and the structuring of services and charges within each department.
      5. We review PS&R reports, outpatient pass through percentages and recent changes, cost-to-charge ratios for different types of services, A/R ratios for outpatient services and the overall cash flow and time sequences of claim generation/billings.
      6. A survey is made as to the preparedness and necessary steps needed to prepare for implementation of APCs (CMS's Outpatient Payment Reform process).
      7. We produce a financial analysis of the potential impact of changes relative to outpatient services.
      8. Additionally, we review areas of concern as expressed by hospital personnel during the on-site studies (within time constraint parameters).
      9. Two consultants on-site for four days are required to address these eight steps. Off-site services include preliminary review of Charge Master and completion of report with suggestions and recommendations. During the on-site visit we hold meetings with various departments and groups of personnel as appropriate. Two consultants are used in order to provide a greater breadth of knowledge to cover all areas concerning outpatient services.
        • Deliverables: The primary deliverable consists of a detailed report relative to the Charge Master and the processing system for billing and filing claims for outpatient services. We make a series of recommendations relative to each of the eight areas listed above. The report addresses the areas that are investigated and those areas in which discussions have taken place relative to possible changes and improvements.
        • Benefits: The primary benefit is the generation of increased revenues for outpatient services. A secondary benefit is to have an assessment of meeting various compliance requirements placed on hospitals for documentation, coding and reimbursement for outpatient services.
        • Costs: Fee developed based upon specific needs.
        • Notes: Follow-up services including special in-service training is available relative to this level of service.

  • Level 2 - Charge Master & Outpatient Coding Review
    • Process & Activities. The process of a detailed study for outpatient revenue enhancement requires a number of steps:
      1. Detailed review of the overall flow of information from the point of service to receipt of reimbursement including the coding, charge development, bill generation, UB-92/HCFA-1500 generation, reimbursement monitoring, denial processing and general information flow including both manual and computer based processing.
      2. Detailed review of the computer system, the various reports available relative to outpatient coding including reports by CPT/HCPCS, productivity studies, the efficiency and effectiveness of the manual interface to the computer system for billing and claims generation, outpatient data base development capabilities and related areas. We pay particular attention to situations in which there are interface problems and response time difficulties. We then explore methods that allow computer system enhancement to assist those in the billing and claims generation process. Further, we perform a review of any encoding and/or optimization software.

      3. Coding review of 100 outpatient charts representing a wide range of coding for surgery, ancillary services and physician services as appropriate. Correlation and review of the patient chart with associated coding analyzed and related to the actual UB-92/HCFA-1500 generated by the A/R computer system. Errors are noted, and patterns relative to coding and/or charging are analyzed.
      4. Detailed review of the Charge Master on a line item basis by department. The following items are reviewed.
        • Service Item Description,
        • CPT/HCPCS Code,
        • Revenue Code,
        • Accounting Code,
        • Charges
        • Overall organization of the Charge Master and the structuring of services and charges within each department.
      5. We conduct a brief review of the PS&R reports along with other quantitative financial measures including pass through percentages and ratios of costs to charges for various departments.
      6. A survey is made as to the preparedness and necessary steps needed to prepare for implementation of APCs (CMS's Outpatient Payment Reform process).
      7. We conduct a financial analysis of the potential impact of changes relative to outpatient services.
      8. Other areas of concern as expressed by hospital personnel during the on-site studies are addressed within time constraint parameters.
      9. The completion of these activities requires two consultants on-site for two days. Two consultants are used in order to provide a greater breadth of knowledge to cover all areas concerning outpatient services.
        • Deliverables: The primary deliverable is a report addressing the recommended Charge Master changes, an analysis and recommendations relative to information flow and the development of claims for outpatient services along with recommendations relative to any problem areas and the steps necessary to prepare for implementation of APCs.
        • Benefits: The primary benefit is the generation of increased revenues for outpatient services. A secondary benefit is to have an assessment of meeting various compliance requirements placed on hospitals for documentation, coding and reimbursement for outpatient services.
        • Costs: Fee developed based upon specific needs.
        • Notes: Follow-up services including special in-service training are available relative to this level of service.

  • Level 3 - Outpatient Revenue Enhancement Study
    • Process & Activities: The process of a detailed study for outpatient revenue enhancement requires a number of steps:
      1. Review of the overall coding-billing-reimbursement process including the use of the computer system and any interface problems.
      2. Review of up to 25 outpatient records including outpatient services, ER, Observation and physician services as appropriate.
      3. Review of the Charge Master on a department and overall structural basis with special attention to changes that will enhance revenues and prepare for implementation of APCs.
      4. Review of other areas of concern as indicated by hospital personnel.
      5. Review of various financial measures relative to outpatient services including PS&R reports, pass through percentages and various specific ratio of costs-to-charges.
      6. In order to complete these steps one consultant on-site for two days is required. Off-site services include Charge Master review (brief) and a post-visit report on suggestions and recommendations.
        • Deliverables: Follow-up report relative to Charge Master changes and recommendations along with recommendations relative to operational structure and the information flow for outpatient billing and reimbursement.
        • Benefits: The primary benefit is the generation of increased revenues for outpatient services. A secondary benefit is to have an assessment of meeting various compliance requirements placed on hospitals for documentation, coding and reimbursement for outpatient services.
        • Costs: Fee developed based upon specific needs.
        • Notes: This is a mini-review service that is very useful for smaller hospitals that need general guidance in the review of their charge masters and a review of their processes and possible problem areas.

For further information, please contact us.