Annual Coding Review

This SOP outlines the process to follow by the Customer Success Team when requesting the annual provider coding review or requesting coding general assistance.

Overview

Medical coding professionals help ensure the codes are applied correctly during the medical billing process, which includes abstracting the information from documentation and assigning the appropriate codes.  The purpose of the coding review is to review the quality of coding to ensure accuracy is met.

Other reasons to perform the annual coding review are:

• To help identify and correct problem areas before insurance or government payers challenge inappropriate coding

• To remedy under coding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures

• To identify reimbursement deficiencies and opportunities for appropriate reimbursement.

• To stop the use of outdated or incorrect codes for procedures

For these reasons, Health Prime offers to all customers 1 annual coding review per provider up to 10 encounters as a courtesy service. Also, Health Prime coding team can assist with general coding questions. The following procedures should be followed when requesting a coding review or for general coding questions.

Coding Review

The coding team will review up to 10 encounters per provider, unbilled or under draft once per 12-month period.  This will be tracked in Hubspot using the Last Coding Review date field from the company record. To include this field to your view click “View all properties”, search and add the property to want to add.

1.   Documentation

The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician's notes, for this reason the coding team requires the claim CMS form and all medical supporting documentation to perform the review.

This information needs to be obtained by the Customer Success Team, prior submitting a ticket.

If the coding team determines there is missing documentation, the ticket will be returned to the ticket originator with the appropriate notes.

All coding documentation will be uploaded to the PMS document system, for example: Kareo documents or the Document Management solution for Next Gen and FiEHR clients. Once the document is uploaded to the PMS, the document ID needs to be included in the Hubspot ticket.

2.   Ticket Creation

Once the documentation is uploaded to the document management software, the Customer Success Team must create an Account Support ticket to track the request.

Create one ticket per provider.  

Before creating a new coding review ticket, confirm that a review was not performed during the last year for the provider. To verify if the provider already had a coding review, please follow the below steps:

1. From Company record > in the right-side panel under Tickets click View all in filtered view

2. Filter your tickets to show only Account Support tickets

3. Type coding in the search area

4. Verify the provider name in the ticket subject and the ticket date

To create the Coding Review ticket, please follow the below steps:

From Company record (use parent company unless child company is the one affected)

• click + Add Ticket.

• Ticket Name: Provider Name + Coding Review

• Pipeline: Account Support Pipeline

• Ticket Status- allow default “1-Submitted” do not edit

• Ticket Type: Coding Review

• Ticket Description: Provide detailed information as the provider name and encounter amount. Included any other detailed information for the coding team including the DOC ID

• Source: Leave blank

• Ticket owner: Creator is the owner throughout the life of the ticket and owns resolution of the request.

• Assignment: @Nilima Kolambkar

• Priority: select appropriate

Consultant and account manager (initial priority)= LOW (Usually always the starting priority)

Escalate ticket to Manager= MEDIUM

Escalate ticket to Director, VP of Client Success & John McDonough= HIGH

When escalating priority on a ticket you MUST create a note in the ticket using the snippet for Account Support Escalation Notes (Shortcut #Escalatedticket) to list all details management will need to help.

• Associated Company: ensure the correct company/ account is listed (parent unless child account is the one affected)

Please be careful when associating contacts/ companies. Uncheck the box to add activity to timeline if you do not want all existing contact emails, notes, etc. attached to your ticket.

• Click Create

• Add note by using #coding and complete the details.

Due Date: select the date allowing 3 weeks to work and resolve. If date needs to be updated to allow time for all updates, work, Etc. to be completed the coding team should meet with RA/ Ops Consultant to agree upon due date.

Ticket follow up: The coding team will add the appropriate notes and the document ID with the review results and will change the ticket status to In Review for the Customer Success team to validate the information, review results with the client and close the ticket by selecting the ticket Coding Review Action: Reviewed with client.

3.   Coding Team Actions

• Once received the coding review ticket the Coding Team Manager will assign to the appropriate team member using the ticket assignment and send an email from Outlook requesting access to the practice PMS. Reference to HPI RCM Help Desk

• The user submitting the access request would document the Help desk ticket ID in Hubspot as a reference.

• After requesting PMS access select the ticket Coding Review Action: Access pending to move the ticket to the Intake status.

• Once PMS access is granted and the documentation validated, select the ticket Coding Review Action: Work In Progress to move the ticket to the In Progress status.

• After completing the coding review:

1. Upload the document with the review results to the appropriate PMS

2. Add a ticket note with the Document ID any important details for the Customer Success team.

3. Send an email from Outlook requesting to remove your PMS access and add the Help desk ticket ID in Hubspot as a reference.

4. Select the ticket Coding Review Action: Coding Review Completed, to move the status to the In Review status, this will also generate a task for the case originator to review the ticket

Coding General Assistance

The customer success team can submit general coding questions, this is an internal tool and should not be given to the customers to directly contact the coding team.

1.   Ticket Creation

From Company record (use parent company unless child company is the one affected)

• click + Add Ticket.

• Ticket Name: Practice name + Coding Question

• Pipeline: Account Support Pipeline

• Ticket Status- allow default “1-Submitted” do not edit

• Ticket Type: Coding Review

• Ticket Description: provide detailed information on what the issue is that you have identified, any supporting documents (use ID only do NOT attach PHI to Hubspot), recommendations, etc.

• Source: Leave blank

• Ticket owner: Creator is the owner throughout the life of the ticket and owns resolution

• Assignment: @Nilima Kolambkar

• Priority: select appropriate

Consultant and account manager (initial priority)= LOW (Usually always the starting priority)

Escalate ticket to Manager= MEDIUM

Escalate ticket to Director, VP of Client Success & John McDonough= HIGH

When escalating priority on a ticket you MUST create a note in the ticket using the snippet for Account Support Escalation Notes (Shortcut #Escalatedticket) to list all details management will need to help.

• Associated Company: ensure the correct company/ account is listed (parent unless child account is the one affected)

Please be careful when associating contacts/ companies. Uncheck the box to add activity to timeline if you do not want all existing contact emails, notes, etc. attached to your ticket.

• Click Create

Due Date: select the date allowing 7 days to work and resolve. If date needs to be updated to allow time for all updates, work, Etc. to be completed you should meet with RA/ Ops Consultant to agree upon due date.

Ticket follow up: The coding team will add the appropriate notes responding to the question and uploading supporting document if applicable, , and will change the ticket status to In Review for the Customer Success team to validate the information and close the ticket by selecting the ticket Coding Review Action: Reviewed with client.