Coding & Compliance Initiatives, Inc

Coding and Documentation Reviews

The coding and billing professionals at CCI are Certified Professional Coders and Licensed Practical Nurses with a full range of expertise in clinical documentation and correct coding procedures. As a result, CCI can assist your organization improve documentation quality, capture charges more effectively, and submit claims for services rendered more accurately.

We have outlined below examples of the coding/billing and documentation services we provide for our clients:

Review CPT/HCPCS and ICD-9 Coding – We will review the selected medical records to verify whether the documentation supports the CPT/HCPCS coding levels reported. Areas of focus include the following:

Verify the accuracy of CPT/HCPCS codes assigned

Review for bundling vs. unbundling, etc.

Review level of specificity for ICD-9 codes assigned

Review for charge capture (i.e. verify the services documented are reported)

Review for Completeness of Documentation/Medical Necessity – A major compliance issue for all providers is ensuring the documentation supports the level of services billed, and that medical necessity requirements have been met and documented sufficiently within the medical records. The clinical and coding professionals at CCI regularly perform medical record reviews to determine our client's documentation properly reflects the level of services provided.

Review for Quality Assurance – In addition to enhancing compliance documentation, our clinical and coding professionals will assist your organization improve its documentation to meet the quality assurance standards for NCQA, Managed Care Plans, Medicare, and other third party payors.

Follow-up Education
CCI will facilitate education for the providers in individualized (or group) sessions based upon the results of the coding and documentation review. CCI will review each record with the respective provider to discuss any opportunities identified for improved documentation and/or coding accuracy.