Mid-sized IP/OP service provider lowered its coding denial rate to under 2%

The Client

Mid-sized IP/OP service provider based out in the US

The Challenges

• Staffing
• Changing coding guidelines
• Case mix & severity
• Hybrid medical records
• Upcoding and down coding DRG along with query process

Plutus Health plan

Plutus Health's highly qualified medical coders detected the issues hindering the client's revenue and systematically approached their IP/OP coding needs.

Issues detected

• The client had incomplete documents leading to improper information extraction.
• The client's internal coding team was not updated with the coding guidelines and rules changes.
• Due to improper documentation, the client was unable to capture case severity which hampered the quality of reporting and reimbursements.
• The client faced difficulty in understanding the coding systems and query process.
• The client's internal team was unable to handle the high volume of records with strict timelines.

After identifying the gaps in the coding process, Plutus Health's certified coding professionals (AAPC, AHIMA) worked closely with the client to resolve coding errors.

Our specialized hospital and facility coders know IP-DRG, OP, and ICD-10 code classification. They have worked on ICD-10-CM, ICD-10-PCS codes, CPT, and HCPCS level 2 code set to thoroughly capture medical procedures and services.

Plutus Health solutions

• Plutus Health's experts reviewed patient notes and determined the most appropriate corresponding codes.
• Our specialists collected appropriate payment payments based on Medicare Severity-Diagnosis Related Groups (MS-DRGs)
• Plutus Health's professionals determined the principal diagnosis for the admission, as well as present on-admission (POA) indicators on all diagnoses.
• Plutus Health's certified (CPC, CCS-P, CIC, CPC-H, COC) coders used the latest set of ICD-10-CM codes, the HCPCS level 2 code set, which includes a section specific to outpatient hospital reporting.
• Plutus Health conducted coding audits to detect unbundling, upcoding, and down-coding issues.
• Plutus Health streamlined all the documents and ensured that all the information was extracted from the documents.
• Plutus supported improved the clinical documentation.
• Plutus supported physician query process.
• Plutus Health leveraged cutting-edge technology to manage the high volume of records and coding requirements.

Results

• Received >98% reimbursement for the submitted claims
• The client increased its revenue by 10% in just 5 months
• Optimized reimbursement for IP or OP services through DRG
• Reduced upcoding and down coding
• Improved clinical documentation
• 5% reduction in query process

Achievements

• Coding denials reached <2%
• Achieved >98% clinical data accuracy rate
• Coding quality reach >95%
• Improved query process based on clinical indicators
• Improved TAT of 48 hours