The health care industry is currently undergoing monumental changes in the U.S. Transition from utilization-based to outcomes-based payment structures has resulted in declining net revenue for many healthcare organizations. Aggressive predictive analytics and extrapolation techniques are aimed at recouping money. In addition to traditional Medicare’s RA coding audits, the RAs, Medicare Advantage, Medicaid and multiple third party payers are ramping up clinical validation audits. Coding and clinical documentation quality directly affects organizational financial performance.

Today, coders and clinical documentation specialists must understand multiple payment methodologies, including Hierarchical Condition Categories (HCCs), APR-DRGs and MS-DRGs. Each of these reimbursement models focus on disease burden. In order to reflect the level of care being provided, coders must to have a deep understanding of disease processes, surgical procedures and coding changes so that ICD-10-CM/PCS codes are applied accurately.

Coding compliance should be considered a top priority to protect net revenue on a continual basis. Benchmarking, monitoring, and continual coder education are crucial steps healthcare organizations can take to protect the bottom line. This presentation is designed to ensure that attendees are prepared to successfully mitigate predatory recoupment activities by all payers by identifying changes in coding and clinical documentation requirements.

Speaker: Lynette Thom, BS, RHIT, CCS, CDIP

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