Quality, Accuracy, Medical Determination Review
J29 provides numerous forms of claims, case, and record analysis all of which as highlighted in our Case Analysis section. Additionally, J29 services the independent quality, accuracy, and medical determination reviews against other entities that have performed the analysis duties. As an independent, and external quality, accuracy, and medical determination reviewers, it’s critical for J29 to support this practice with the most advanced and knowledgeable subject matter experts that can support the most advanced level of program oversight reviews.
Medical Determination Review
J29 specializes in providing independent or external medical reviews, which handle submissions from beneficiaries, payers, providers, legal representations, care givers, and require clinical expertise to provide quality gate reviews on the initial determination.
Through the reviewing process, our team uses expertise on treatment, surgeries, pricing, primary care, prescriptions, and additional medical-related costs for Part A, B, and D of Medicare, and Medicaid. Aside from independent reviews, J29 has provided appeals reviews on initially denied billing claims for beneficiaries, where a disagreement has been reached and we work to mitigate the reasoning. Through the appeals process comes varying local, State, and Federal laws that our team takes into consideration when making appeal determinations.
J29 supports accuracy reviews of analysis programs, and is continuing to provide this oversight for the Center for Program Integrity at CMS. Using Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Professional Healthcare Quality (CPHQ), Certified Professional Coder (CPC), Certified Instructor, Professional Medical Coding Curriculum (PMCC),and Certified Professional Biller (CPB), our team is able to support our claim of having the most advanced and knowledgeable subject matter experts. We continue to provide quality and accuracy oversight on coding and billing sequences, such as:
International Classification of Diseases (ICD) 9/10 Code Applicability Verification
Cross-Walk from ICD 9 to ICD 10-CM Accuracy Review
Current Procedure Terminology Codes (CPT)
Healthcare Common Procedure Coding System (HCPCS)
Procedure Billing Applicability Quality Reviews (i.e per specimen, per analyte, etc.)
Diagnosis Related Group (DRG) Codes
Our quality, accuracy, and medical determination review team supports quality improvement initiatives for State and Federal agencies, where we are taking our findings from reviews and working to develop improvement initiatives to prevent such mistakes from occurring in the future.