In-depth, Focused Retrospective Chart Reviews
Medical coding involves multiple steps and accurate coding. In order to appropriately code medical information, coders must be experienced and understand the detailed oriented role of reviewing patient medical charts. Medical coding is the translation of healthcare diagnosis, procedures, medical services and equipment into universal alphanumeric codes. The medical information such as the patient diagnosis, procedures, treatments, etc. are recorded into the patient medical charts in the physician notes, laboratory, and other finding results. Medical coding professionals ensure that codes are correctly used for the medical billing process. Coding includes abstracting the information from the medical documentation, assigning the appropriate codes, and creating a claim that will be paid by insurances.
Understanding Retrospective Chart Reviews
Since medical coding involves reviewing the medical charts, it’s important to understand what exactly a retrospective chart review is. A retrospective chart review or medical chart audit is when a coding specialists go backs to the chart to review the information to make sure targeted of specific things in the patient medical chart is appropriately coded. Retrospective review usually occurs after care has been received by patients and the claims have already been submitted to the payer. The retrospective reviews often uncover codes that are supported by the medical record that were missed or not reported. The retrospective reviews also uncover codes that should not have been submitted because they did not officially meet the documentation coding guidelines. Because retrospective chart review approaches are conducted later than in real time, the clinical documentation issues that are identified are likely longstanding ones. This process typically requires a secondary workflow to flag the charts and send the corrected coding information to the payers. This process of retrospective chart reviews is often used with the Medicare Advantage programs.
Complete Your Retrospective Chart Reviews With Us
If you are interested in conducting retrospective chart reviews with your coding and would like some help, reach out to our team at HCC Coders. Give us a call at 877-328-2343 to see how we can work with you to accomplish your chart reviews. We have a specialist team experienced with HCC medical coding. Our qualified coding professionals are ready to assist you with all of your HCC coding needs and projects. Know that when you team with us, you are working with the best in the industry. Our experts understand the importance of accurate coding and appropriate retrospective medical chart reviews to maximize returns.