Operational Assessments/Internal Investigations

Operational Assessments:

Since 2000, Coding Continuum, Inc. has conducted operational assessments for its clients, ranging from single practitioner outpatient offices to large academic settings. Significant changes in the healthcare environment have prompted evolution and development of clinical enterprise models, networks, Accountable Care Organizations, and mergers and acquisitions. The drive for quality improvement, coupled with reductions in reimbursement, has resulted in the need to improve operational processes while reducing costs through consolidation of services via shared or centralized service models. Coding Continuum, Inc.’s primary goal and interest is to support clients whose needs are specific to the discipline of health information management in the context of operations, compliance, clinical documentation improvement, and revenue cycle administration. Its Senior Consultants have a minimum of twenty years of operational experience in their respective areas of expertise, including direct responsibility for process and quality improvement in high volume, highly complex healthcare facilities. They include academic medical centers with Level I Trauma services, critical care services (including Pediatric/Neonatal Intensive Care units), NCI cancer centers, psychiatric services, subspecialty surgical services, and outpatient clinics. They possess extensive experience in Patient Financial Services, Health Information Management, Clinical Documentation Improvement, and other critical organizational functions that impact revenue and compliance with Federal, State and third party payer requirements. In addition, Coding Continuum, Inc. has extensive experience with accreditation standards associated with Medicare Conditions of Participation and Joint Commission.

Coding Continuum, Inc. advocates a team approach with all of its projects, tailoring each one to meet the needs of the client and to ensure that project goals are met.

Internal Investigations:

Coding Continuum, Inc. principals and consultants possess years of experience working with clients regarding highly sensitive issues that require investigation and assessment. Whether directed by Counsel or Compliance Officers, Coding Continuum, Inc. independently investigates and evaluates reported or internally-detected compliance risks that may necessitate client self- disclosure to Federal, State and/or other third parties. In addition to performing forensic audits, our professionals are prepared to rapidly respond to emergent compliance concerns by conducting on-site comprehensive and in-depth interviews, reviewing internal correspondence, policies and procedures, and assessing existing operational processes and protocols. Our rapid response team is made up of individuals whose educational background and administrative and technical experience is specific to the subject matter or issue requiring investigation.

Audit/Compliance Services

Coding Continuum, Inc. professionals provide audit and compliance services, including internal and external coding audits in all healthcare settings. Coding Continuum, Inc. staff work collaboratively with Compliance Officers and Corporate Counsel to perform periodic as well as focused reviews based upon client needs.

  • Coding Continuum, Inc. professionals have experience assisting with implementation of Corporate Integrity Agreements as well as responding to Centers for Medicare and Medicaid Services reviews associated with pre- and post-payment audits, Medical Reviews, Program Integrity/ZPIC audits, RAC audits, and quality reviews.
  • By virtue of years of experience both in provider as well as payer settings, Coding Continuum, Inc. professionals are equipped to assist compliance programs in addressing internal as well as external concerns. In the provider setting, they have been instrumental in developing risk tables and action plans designed to minimize vulnerabilities to external audit processes. Previous Centers for Medicare and Medicaid Services contractor experience has been instrumental in assisting organizations in understanding Medicare Administrative Contractor requirements as well as developing strategic initiatives designed to respond to ongoing changes in a dynamic healthcare environment.
  • In addition to its work with Federal and State program compliance, Coding Continuum, Inc. has extensive experience with commercial third party audits. Its work includes assessment of third party determinations and challenging payment denials and adverse determinations.
  • Education is a core component of Coding Continuum, Inc.’s audit and compliance services. Coding Continuum, Inc. professionals possess years of experience as educators and are prepared to provide one-on-one training as well as group education on topics ranging from Evaluation and Management coding, specialty specific CPT® coding, MS-DRGs, APCs, and other reimbursement methodologies. In addition, Coding Continuum, Inc. has been proactive in its preparations for ICD-10-CM/PCS. A number of Coding Continuum, Inc. consultants have become AHIMA-approved trainers to ensure that clients receive the most current information and training on the nomenclature that is scheduled for implementation in October 2015.

Litigation Support

Coding Continuum, Inc. provides litigation support, consultation and expert testimony on behalf of defendants and plaintiffs in matters pertaining to allegations of improper medical coding and/or billing, including provision of medically unnecessary services. Its experts have been qualified in both civil and criminal court. In addition to the provider community, Coding Continuum, Inc. clients also include the Department of Justice (including offices of the United States Attorney and Federal Bureau of Investigation), some of the largest insurance carriers in the United States, nationally-recognized law firms, and self-funded health plans.  In addition to its work for the Department of Justice, Coding Continuum, Inc. has also been retained as an Independent Review Organization (“IRO”) by a number of clients who are operating under Corporate Integrity Agreements (“CIA”) pursuant to settlements with the Office of Inspector General (“OIG”).

The majority of Coding Continuum, Inc. Senior Consultants have a minimum of twenty years of coding and operational experience in their respective areas of expertise, including high volume, highly complex healthcare facilities.  They include academic medical centers with Level I Trauma services (including Pediatric/Neonatal Intensive Care units), community hospitals, NCI cancer centers, psychiatric/behavioral health services, subspecialty surgical services, SNFs, IRFs, LTACs, home health, hospital-based and freestanding outpatient clinics, small/large practice groups, and other settings.

Coding Continuum, Inc.’s coding/auditing consultants have extensive experience evaluating the accuracy of ICD-9-CM, CPT® (including E/M coding), HCPCS, and modifier use.  They are well acquainted with coding rules and conventions as well as guidelines regarding proper use of specific nomenclatures, reimbursement methodologies such as MS-DRGs, CMGs, and Federal/State claims submission and benefit policy manual requirements.  A number of Coding Continuum, Inc. consultants possess the CPC-I credential accorded by the American Academy of Professional Coders.  The majority of Coding Continuum, Inc.’s coding experts are dually-credentialed by the American Health Information Management Association (AHIMA) and the American Academy of Professional Coders (AAPC).

In addition to its group of skilled coding professionals, Coding Continuum, Inc. employs clinical and administrative experts, including nurses, physical and respiratory therapists, clinical documentation specialists, health information management professionals, reimbursement experts, cost report experts, and contracting experts.  Coding Continuum, Inc. also enjoys a collaborative relationship with a physician-based firm specializing in medico-legal analysis.  This affords our clients a single source solution for its coding, billing and medical expert needs.

Prospective Payment and Medical Necessity Expertise

As referenced above, Coding Continuum, Inc. consultants possess years of experience applying various coding nomenclatures, including those which are critical to proper assignment of MS-DRGs, MS-LTC-DRGs, RUGs, CMGs, APCs, and others.  Knowledge of ICD-9-CM coding rules and conventions as well as ICD-9-CM published guidelines is the most critical factor in determining the accuracy of prospective payment system billing such as MS-DRGs, MS-LTC-DRGs and CMGs.  Coding Continuum, Inc. has performed many audits whose focus has been acute and long term inpatient hospital care, independent rehabilitation and skilled care.  The majority of audits have been provided in the context of litigation support involving civil or criminal investigations.

In addition to its work related to proper coding and grouping, Coding Continuum, Inc. has been retained by both plaintiffs and defendants in matters related to evaluation of medical necessity.  Application of both InterQual and Milliman and Robertson screening criteria has been a component of its work as well as application of payer-specific guidance regarding medical necessity.  Coding Continuum, Inc. clients also include providers who wish to evaluate the propriety of inpatient and outpatient care delivery as part of internal compliance program initiatives and process improvement projects.


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