Coding Compliance and Data Quality Audits

A structured coding and billing audit validation program will assist your facility in correcting flaws that may reduce revenue, as well as keep you prepared for the escalating levels of external scrutiny imposed by government regulators.

As an external, non-biased, third-party, Healthcare Cost Solutions (HCS) provides various audit services by credentialed coding professionals experienced in coding and reimbursement compliance. Our on-site and remote validation audit processes assist your organization in identifying and correcting occurrences of "over " and "undercoding." An Exit Conference education session is conducted with the coding staff at the conclusion of every audit. CEUs are awarded to all staff in attendance. Recommendations for coding changes are supported by authoritative, official coding and billing references. Potential documentation issues are identified and a comprehensive documentation of findings is provided in a detailed summary report.


  • DRG Audit
  • Through a review of inpatient records, a DRG audit assesses the accuracy and validity of ICD-10-CM/PCS diagnosis and procedures and corresponding DRGs. At the discretion of the client, discharge status assignments and present on admission indicators are also verified.
  • Full APC Audit
    A Full APC Audit includes a review of all procedures assigned on the UB-04 and the patient's bill. Reviewing outpatient surgery, clinic and/or emergency room records will ensure compliance with CPT and HCPC procedure codes, corresponding APCs, and ICD-10-CM/PCS diagnosis and procedures.
  • Partial APC Audit
    As in the case of the Full APC Audit, a Partial APC Audit consists of reviewing outpatient surgery and/or emergency room records, results in the CPT and HCPC procedure codes, corresponding APCs', and ICD-10-CM/PCS diagnosis and procedures assessed for coding compliance. The UB-04 and the patient's bill, may also be reviewed, however, this audit does not include the Chargemaster System's review of procedures.
  • ICD-10-CM / PCS Inpatient Review
  • Review of inpatient accounts for accuracy of ICD-10-CM/PCS assignment with feedback and education to the coding staff.
  • ICD-10-CM / PCS Outpatient Review
  • Review of assigned ICD-10-CM diagnosis audits for outpatient accounts, with feedback and education to the coding staff. If you are having your outpatient staff assign ICD-10-PCS codes for internal reporting, HCS can review those as well.
  • ICD-10-CM / PCS Time Study
  • To help facilities determine the impacts of ICD-10 on coder productivity, HCS offers time studies. Our trained auditors review and natively code accounts using ICD-10-CM/ PCS to determine the average length of tie for your facilities accounts. Identification of potential documentation issues resulting in delayed billing is identified as well.
  • ICD-10-CM / PCS Clinical Documentation Review
  • Review of provider's documentation to identify areas of documentation likely to impact reimbursement and result in increased queries and delayed billing.
  • Recovery Audit Program
    The Recovery Audit Program offers support in preparation, education, trending, case review, preparation of appeals, and tracking. There are also MAC and MIC reviews and appeals available. With the development of the California Recovery Audit Program in 2006, HCS auditors' are highly experienced and possess advanced competence in the Recovery Audit review and appeal process.
  • PACT Accuracy Audit
  • The PACT Accuracy Audit validates the Post-Acute Care Transfers by identifying variances in patient discharge dispositions that impact organizational reimbursements on inpatient discharges of one of the 273 transfer MS-DRGs under the Medicare PACT policy.
  • HCC Audit
    The HCC Audit examines managed care charts for incomplete coding and/or over coding in the Hierarchical Condition Categories.
  • Intervention Radiology Audit
  • The Intervention Radiology Audit consists of outpatient intervention radiology records where CPT and HCPC procedure codes are reviewed for coding compliance. ICD-9-CM diagnosis and UB-04, the patient's bill, may also be examined.
  • Long Term Acute Care Audit
    The Long Term Acute Audit assists the Long Term Acute Care facilities with their compliance efforts by monitoring government standards related to clinical documentation and coding assignment.
  • OIG High Profile Cases
    OIG High Profile Cases evaluates high profile cases with the support of provided cases reviews. OIG High Profile Cases conducts a summarization of findings, feedback, and education for hospital staff.
  • Revenue Cycle Assessments
    HCS will partner with you and your staff to determine areas for revenue cycle improvement and provide necessary services to address these areas resulting in financial enhancement.
  • Professional Fee Coding Audit
    The Professional Fee Coding Audit consists of a review of physician office/clinic or hospital based physician notes, ICD-9-CM diagnosis and CPT procedure codes for professional fee billing.
  • Medical Necessity Reviews
    The Medical Necessity Review provides an experienced nurse auditor to evaluate the level of care provided based on the severity of illness, intensity of service, and physician orders for inpatient admissions.
  • Itemized Charge Detail Audit
    The Itemized Charge Detail Audit includes an experienced nurse to review the itemized bill against documentation in the medical records to verify items charged. A summary of findings will be presented at the conclusion of the audit.


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