A Description of PRC’s

Outpatient Coding Compliance

and Reimbursement Reviews 

In addition to validating code assignments, PRC will identify services that were provided but not coded/billed, as well as services that were coded/billed but not documented.   PRC also reviews encounters to validate proper coding  to the highest level of specificity to support Medical Necessity Coverage for your geographic area.  We provide our recommendations in a comprehensive report with each case re-abstracted while indicating potential financial impacts.  Our final reports also provide useful statistics such as accuracy rates, which can be customized to be Coder specific and/or as a group, to best fit the needs and objectives of Client.  PRC will conduct Coding Education Sessions to present review findings and recommendations.

The Depth of PRC's Outpatient Review

In order to reach and maintain compliance, and to receive optimum reimbursement on your Outpatient claims, ALL coding needs to be current and accurate.  It is important to mention that our Outpatient consulting staff is cross-trained in Charge Master Maintenance.  Therefore, PRC brings another level of depth to our Outpatient Coding Compliance Reviews by having the expertise to evaluate the CDM driven charges/codes, as well as the soft-coded codes assigned by the HIM Coders. 

We request to review the ‘final’ bill (i.e., UB-04) to ensure that all mapping of codes and charges are appropriate, and to identify any issues that could arise while the codes, modifiers, and charges travel through the entire process.  This is important since it is PRC’s experience that some issues arise after the chart has been coded by the HIM Department, for example, if/when an encounter may trigger an OCE or NCCI Edit later in the process.

Major Objectives of an Outpatient Review

  • ​Verify the Accuracy of the ICD-10-CM Diagnosis Codes

  • Verify the Accuracy of the CPT Codes

  • Validate HCPCS codes and Service Units

  • Verify the Accuracy of the E&M Codes

  • Verify the Accuracy of the Modifiers

  • Evaluate the Level of Documentation

  • Verify the Accuracy of Billing

    • Review UB-04’s for Accuracy and Proper Mapping of Codes/Charges

    • Review Detail Bills (i.e., Itemized Statements) for Accuracy

  • Review for Medical Necessity
  • Verify Overall Compliance
  • Evaluate the Handling of Edits:

    • OCE (Outpatient Code Editor)

    • MUE (Medically Unlikely Edits)

    • NCCI (National Correct Coding Initiative) Edits

  • Review Group Assignments (i.e., APC Assignments, and Understanding where CAH OPPS Exemptions apply)

  • Education (AHIMA and AAPC recognized CEU's for Coders)