Introduction
WWS’s internal review process helps us ensure high-quality coding and billing. We work with providers to ensure that their claims are as accurate as possible, which is why we recommend a 30-day Internal Review (IR) for all claims. The IR process uses the same methodologies used in an External Review (ER). However, instead of sending your claims out for an external review by an outside expert, we perform the review internally.
Clinical Coding Review (CCR)
CCR is a quality assurance process that helps us ensure our coding and billing practices are accurate, up-to-date, appropriately attributing evidence-based sources, and contextually appropriate for Healthcare communities.
CCR includes reviewing clinical records to identify:
1) missing or erroneous codes;
2) coding errors;
3) potential abuse of the CPT manual;
4) unnecessary use of modifiers (coding descriptions added to reflect clinical circumstances); and
5) potential duplication of services billed by different providers in the same episode of care (i.e., double-billing).
How Is CCR Different From External Review?
● CCR is an internal review. External review is performed by an external auditor.
● External review is mandatory. An internal review is voluntary unless required by law or regulation, but it’s highly recommended because of the benefits outlined below.
● External reviews are more rigorous than internal reviews and thus require more time and effort to complete. They also cost more because they often require independent third-party support.
● The benefit of external review: they provide a level of validation that can be used as evidence if you are ever questioned about compliance with auditing standards or need to demonstrate compliance in response to an inquiry from regulators or investors (e.g., “Yes, we have been audited annually for the last 10 years”).
What Are the Benefits of WWS’s CCR?
CCR is a way to improve our coding and billing practices. CCR helps us identify areas for improvement, including:
● Improving the accuracy of how we code and bill our procedures, tests, devices, and other services
● Ensuring that our coding and billing practices are accurate, up-to-date, appropriately attributing evidence-based sources, and contextually appropriate for Healthcare communities.
Who Is Eligible for a CCR?
You’re eligible for a CCR if you:
● Are a clinician, physician, physician assistant (PA), nurse practitioner (NP), or nurse a DME Provider who bills Medicare Part B claims or Medicaid claims.
● Have billed any Medicare Part B or Medicaid claim within the last two years.
How to Perform a CCR For Your Practice?
● Provide evidence to support your request. The more information you can provide about the situation that led to your CCR, the better informed those reviewing your case will be.
● Explain in detail what happened and why it should be considered a learning experience rather than a violation of the integrity policy.
● This detail will help those reviewing your case understand what motivated you in making this decision.
WWS’s internal review process helps us ensure high-quality coding and billing.
The CCR process is a way for us to evaluate your clinical documentation and make sure it meets our standards for quality. As part of this process, you may be asked to revise or correct your documentation if it doesn’t meet our guidelines.
Conclusion
The purpose of the internal review is to ensure that the organization’s policies and procedures are being followed. When an organization has a solid set of policies and procedures, it provides a good foundation for its employees’ work efforts.
