Case Categorization

Cases will be categorized in accordance with the Degree of Complexity listed below:

Straightforward
Single surgeon’s case review needed to consider minimal coding and documentation presented for line item discussion specific to coding and documentation in the operative note and associated coding.

Reimbursement will be evaluated in accordance with National Reimbursement Guidelines, CMS regulations, or State Specific Rules. The governing body that is the regulatory agency for said claim.

Difficult
Single surgeon’s case review needed to consider coding and documentation presented for line item discussion specific to coding and documentation in the operative note and associated coding, to evaluate denials for bundling, proper use of modifiers.

Reimbursement will be evaluated in accordance with National Reimbursement Guidelines, CMS regulations, or State Specific Rules. The governing body that is the regulatory agency for said claim.

Complex
Single surgeon’s case review needed to consider minimal coding and documentation presented for line item discussion specific to coding and documentation in the operative note and associated coding. Discussion and consideration will be given to primary and “additional” level coding, modifier application, bundling and denial conditions. Review encompasses the consideration of medical necessity, modifier applications, bundling and denial conditions.

Reimbursement will be evaluated in accordance with National Reimbursement Guidelines, CMS regulations, or State Specific Rules. The governing body that is the regulatory agency for said claim.

Comprehensive
Multi-surgery team involved in the case, considering extensive coding for each surgeon, the documentation for all codes and independent operative notes. Discussion and consideration will be given to primary and “additional” level coding, modifier application, bundling and denial conditions. Review encompasses the consideration of medical necessity, modifier applications, bundling and denial conditions.

Reimbursement will be evaluated in accordance with National Reimbursement Guidelines, CMS regulations, or State Specific Rules. The governing body that is the regulatory agency for said claim.

Each Category will require a prepaid fee, and all of the documents and assistance necessary for full disclosure, and continued anonymous communication, when required, with the investigative team via the case administrator.

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