William Dagher looks at clinical chart reviews and argues for the deployment of medical coding-certified physicians to reduce unnecessary high cost claims.

Combating rising healthcare costs

Berkshire Hathaway Inc, Amazon.com Inc and JPMorgan Chase & Co are forming an ambitious joint venture aimed at lowering the cost of health care. These three companies representing one million workers face challenging healthcare cost inflation headwinds.

From 2011 to 2016, family health insurance coverage premiums rose by 20% despite only an 11% increase in wages. The resistance to healthcare change and innovation is fierce because the incentives throughout the healthcare industry are not always properly aligned. These conflicted incentives exist in workers’ compensation and can be a meaningful source for unnecessary care and medical procedures.

The good news is that employers can reduce the cost of high cost claims through the deployment of clinical chart review which utilizes medical coding-certified physicians reviewing high dollar workers compensation claims along with their associated medical records. It is not enough for a physician that is not versed in medical coding to review the chart because these physicians tend to focus on the medical appropriateness of care. When a physician is versed at the intersection of appropriateness of care and medical coding, the results can be impressive.

The devil is in the details

Take, for example, a typical case where a patient undergoes a surgical debridement of wounds. You will find that the provider could bill for CPT code 15004, which is for surgical preparation or creation of recipient site by excision of wounds representing a fee north of $21,000. When a medical coding-certified physician reads the medical documentation and translates the documentation to the actual CPT code, they could find that CPT code 11042 should be utilized, which more accurately represents the actual procedure of debridement, skin and subcutaneous tissue for the first 20 square centimeters or less. The charge for CPT code 11042 is south of $700. This is a saving of $20,000.

Quite often, emergency rooms attempt to bill CPT codes 99291 and 99292 for critical care services when none of the diagnoses or supplied medical information submitted indicate impairment of one or more vital organs, or imply an imminent or life-threatening deterioration of a patient’s condition. The charges for two CPT codes representing $5000 and $28,000 can be disallowed by the employer as unsupported by the clinical documentation, resulting in savings of $33,000 to the employer.

When an employer can take the preemptive approach of deploying medical coding-certified physicians to review high dollar workers compensation claims along with their associated medical records, meaningful savings can be achieved.

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