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Medical Coding Risk Adjustment and Physicians’ Pay by Nitin Thakor, President and CEO, GeBBS Healthcare Solutions


A recent article in Neurology Today covered the story of how a federal lawsuit is claiming that UnitedHealth Group (UHG), the nation’s largest Medicare Advantage insurer, is inappropriately coding medical claims for financial gain. This shines the spotlight on how medical codes are used for risk adjustment. This is the basis for the Department of Justice’s interest in UHG, and a medical coding topic that every physician practice needs to be aware of.

The codes at issue are complicated, tedious, and frustrating for physicians who just want to take care of their patients. But they are already being used to compare physicians to their peers, and as value-based payment systems gain traction, the codes will influence insurance contracting opportunities and physician pay.

“This is going to be an increasingly important way that healthcare will be evaluated and paid,” said Eric Cheng, MD, FAAN, a neurologist and health services researcher at the David Geffen School of Medicine at the University of California, Los Angeles.

Hospitals and healthcare providers are facing profound challenges, while trying to their achieve revenue goals without jeopardizing quality and meeting “hard to comprehend” regulatory compliance requirements. Having a commitment to coding quality is the key to having a successful revenue cycle, and it’s all being tested by the DOJ, RAC, the MAC, and ICD-10. How can providers be sure that they’re not at compliance risk and leaving revenue on the table?

The answer is: professional coding compliance audits that can help answer these challenges.

A professional coding and documentation compliance audit is comprehensive and relevant for today’s healthcare environment. It should employ a proprietary and proven methodology that is designed to assess your coding accurately and offer you the opportunity to reach the operational excellence for which you are striving. After the coding compliance audits are completed, you should receive a detailed and customized report outlining the findings on how you can improve your coding accuracy, your clinical documentation, and your reimbursement levels. This approach will assists you with meeting CMS, AMA, AHIMA, AHA standards, and DOJ compliance issues for the proper levels of coding and risk adjustment.

Professional auditors of the highest caliber may use propriety technologies such as iCode Assurance, a customizable coding audit solution. You can be assured and confident that outsourced professional auditors are credentialed, experienced and passionate about getting even the smallest details right. They have worked with hundreds of hospitals, physician groups, and other healthcare companies to help them find inefficiencies, eliminate errors, and follow best coding practices.

Be sure you are in compliance and getting reimbursed at the highest appropriate levels – take advantage of a professional coding audit!

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