May 2021 | Get the latest from the best RBP advocates and auditors
Audit Spotlight
Cynthia Swanson, RN, CPC, CEMC, CHC, CPMA
Senior Audit Manager
Audit of hospital inpatient care uncovers coding errors and over-inflated hospital charges
Case Scenario
Member received inpatient hospital surgical services for the treatment of diverticulitis of the small bowel with perforation. The hospital submitted their claims (initial and corrected) to insurance with total charges of $88,248.30. High dollar charges included six days of room and board for $42,312.00 and operating room services for $11,286.00.
In this case, the hospital located in New Jersey reported the diagnosis code of COVID-19, U07.1 along with other diagnoses on the initial claim billed/submitted. The ClaimDOC Audit Team reviewed the claim and itemized bill and did not identify any hospital services typically provided to COVID-19 patients. There was a charge for a COVID-19 laboratory test, however, this test has become common or hospital policy for patients undergoing surgical procedures. Additionally, merely because a COVID-19 test was ordered and performed, it does not mean it was a positive test result. Based on this preliminary analysis, it was determined medical records would be requested to confirm the accuracy of the reported COVID-19 code U07.1, DRG code 329, and the appropriateness of the additional weighted DRG reimbursement.
Comprehensive line-by-line claim auditing by healthcare professionals is used to uncover errors typically not caught. ClaimDOC publishes a sample of five recent client savings audit results bi-monthly. See the savings below and know that together we can make healthcare affordable.
1. Pittsburg, PA
Hospital outpatient services for the treatment of osteoarthritis of left hip and related surgery
Disclaimer – The analysis of any medical billing or coding is dependent on numerous facts, regulations, payer policies and codes, as well as the controlling plan description. The information contained herein is intended to provide a real-life example of opportunities for savings through ClaimDOC services but is not intended to provide medical, legal, or financial advice.
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