TTG Financial Consulting - Coding, Charge Description and Master Reviews

The Toiyabe Group, Inc. (TTG) is uniquely qualified to help you prepare for and minimize the potential financial impact on your facility. TTG has a proven track record in appealing ZPIC and RAC audit

By utilizing our “RAC Audit Risk Assessment” you will identify:
	Your facility’s vulnerability to ZPIC and RAC-targeted DRGs;
	Medically unnecessary inpatient and observation admissions;
	Documentation “black holes;”
	Appropriate charge methodology;
	Work flow issues which can be addressed proactively.

Post audit support activities:
	Report to all levels of Management impacted by ZPIC and RAC audits with recommendations for issue resolution;
	Education for clinicians at all levels to improve documentation protocols;
	An option to include CDM review, pricing and maintenance.

We can also review any ZPIC and RAC audits already performed to:
	Determine if sound coding and utilization rationale is used;
	Determine if the financial impact is significant enough to warrant an appeal;
	Initiate and follow through with the appeal process using physician determinations of medical necessity.

The Toiyabe Group, Inc. can partner with leading healthcare law firms to perform Mock Audits under Attorney Client Privilege or with your legal counsel.

Our RAC risk assessment includes:

Review of the selected claims:

Utilization review for medical necessity;

Line-item review for correct billing and documentation of services;

Coding review for:

		Bundled/unbundled services;
		Appropriate coding of documented services;
		Appropriate coding of diagnoses, as documented in the chart at the time of service.

Utilization Management:

InterQual or Milliman utilization review standards will be utilized to determine appropriateness of admission and length of stay;

RNs with UM experience will conduct the TTG review;

TTG will report UM variances found to assist Management in identifying needed changes or education.

Line-Item Bill Review will be performed by RN auditors

To identify over and under billed services as documented in the medical record;

TTG will apply Medicare regulations as to bundling and unbundling billed services;

TTG will report to Management over and under variances by Revenue Code.

Coding review will be performed by Certified Professional Coders to emulate the RAC vendor’s approach to the audit:

TTG will audit CPT and ICD-9 coding;

Coding variances will be reported to Management by line-item for CPT coding;

TTG will report ICD-9 variances as billed on the UB-04.

TTG’s Audit Process Includes:

Identification of Project Coordinator(s) and the responsible personnel involved with the clinical and financial transactions for the Medicare billing cycle;

Confirmation of on-site dates and the availability of key personnel;

Review of medical record charts and data, including UB-04 / HCFA 1500, EOB/RA, Medical Progress Notes, Orders, Labs and other ancillary service documentation.

Report of Audit Findings to Management:

Exceptions and variances reported by revenue code;

		Identify the UM findings;
		Identify the bill audit findings;
		Identify the coding audit findings.

ZPIC and RAC Audits and Appeal Assistance