Contractor shall conduct quarterly audits of providers for all lines of business through the review of organizational documents and records to verify compliance with regulatory requirements; address and support coding practices that optimize Health Centers long term sustainability; analyze and support risk revalidation efforts; and suggest opportunities to improve risk coding practices. Work may include, but is not limited to: • Evaluate documentation to ensure it supported the services provided and billed. • Assess the fulfillment of medical necessity for the services reviewed. • Conduct a comprehensive review of all relevant coding types: o CPT codes, including Evaluation and Management (E&M) levels and appropriate modifiers o CDT codes, including utilization of appropriate HCPCS or ICD-10-CM codes and modifiers o HCPCS codes. o ICD-10-CM coding accuracy. • Ensure compliance with regulatory guidelines for medical documentation and billing. • Identify discrepancies between services documented and services billed to address potential compliance risks. • Validate the accuracy of CPT, HCPCS, and ICD-10-CM coding to maintain billing precision...
