VIable

NDHI
NAT IONAL DIALOGUE FOR
Healthcare Innovation
Coding Advisor
Organization Overview
• Change Healthcare is committed to connecting the
dots between payers, providers, and patients, by
using data analytics to deliver predictive insights
to these clients
• Change Healthcare operates the single largest
financial and administrative healthcare network in
the United States
• The company offers a diverse portfolio of solutions
to help payers, providers, and pharmacies operate
efficiently and effectively
Background
Care practitioners are reimbursed for assessing and
managing patients’ health through a set of Current
Procedural Terminology (CPT) codes called “evaluation
and management” (E/M). These services represent
a significant portion of healthcare billing – 30%
of Medicare Part B payments were for E/M codes in
2010. Improper coding for E/M services is a significant
concern for payers and puts undue financial burden
on the broader healthcare system. The extent of E/M
misuse has been the subject of a report published by
the Office of Inspector General, which found that:
• Medicare paid $6.7 billion in inappropriate E/M
claims in 2010 alone
Traditionally, insurers often pay out claims before
investigating them, due to the short time frames that are
legally-required for provider reimbursement, and then
conduct post-payment audits. When improper coding
occurs, this causes payers to engage in a “pay and
chase” model to adjust reimbursement appropriately to
providers. Due to the high cost in pursuing low dollar,
high-volume claims, payers have historically been unable
to effectively pursue these types of overpayments.
Product Details
Coding Advisor is an innovative platform developed
by Change Healthcare to transform payment integrity
services for the healthcare payer industry. This product
was developed to address the widespread issue of
overpayment by insurers due to:
• Outlier physician E/M upcoding
• Misuse of “modifier 25” for E/M coding
• Unit errors associated with high cost injectable
“J-Code” billings
• 55% of Medicare claims for E/M services were
incorrectly coded or lacking documentation in 2010
FOUR PHASE CHANGE IN BEHAVIOR APPROACH
PHASE 1
Identify
PHASE 2
Educate
PHASE 3
Validate
PHASE 4
Act
CHANGE IN
BEHAVIOR
• Outlier Identification
• Establish Baseline
• Outlier Reports
• Outreach Calls
• Coding Policies
• Probe Audits
• Document Error Rate
• Transactional Messaging
• Documentation and
Case Summary
• SIU Action Plan
An Initiative of the
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Coding Advisor