Medical Coding and Auditing Services
Medical coding and auditing that holds up under scrutiny
Verve provides comprehensive healthcare claims review, medical coding, and auditing services. The work supports clinical integrity, accurate reimbursement, regulatory compliance, and proactive fraud, waste, and abuse (FWA) detection, reducing audit risk for healthcare organizations.
Enterprise support is delivered to federal agencies, healthcare plans, hospitals, physician practices, billing companies, and healthcare systems with precise, compliant, and timely review and coding solutions.
Overview
Enterprise support across federal health programs and commercial payers
A team of elite, certified specialists, including in-house Registered Nurses, bridges the gap between clinical documentation and fiscal accuracy, minimizing audit exposure for hospitals, physician practices, and large-scale federal health solutions.
Core competencies
What the team covers
Medical coding and audit
- Medical coding: ICD-10-CM/PCS, CPT®, HCPCS Level II
- Inpatient, outpatient, professional, and facility coding
- Emergency department coding
- Surgical procedure coding
- Reimbursement classification
- E/M coding (current regulations and past 95/97 guidelines)
- Prospective and retrospective coding audits
- Medical claims review and validation
- DRG validation and MS-DRG/APR-DRG audits
- Compliance and documentation audits
- OIG and payer readiness audits
Compliance and education
- Coding compliance program support
- Provider documentation improvement (CDI support)
- Provider clarification
- Secondary quality review
- Coding education and feedback reports
- Policy and procedure development
Clinical claims review and medical integrity
- Daily research and rigorous review of assigned caseloads for accurate billing, identification of fraud, waste, and abuse indicators, and validation of medical necessity against complex national and state policies
- In-depth documentation analysis for claim approval or denial under strict CMS and MAC regulatory hierarchy
- Comprehensive review of national and state policies to support medical necessity determinations
- Specialized expertise in Medicare Part B post-pay claims, with a niche focus on skin substitutions, durable medical equipment (DME), home health, and behavioral health claim types
Medical review
Determinations that are accurate, consistent, and defensible
Verve provides medical review services that combine clinical expertise, healthcare policy knowledge, coding proficiency, and data analysis.
Review services
- Medical necessity review
- Clinical documentation assessment
- Coding validation
- Coverage and payment review
- Prepayment and post-payment review
- Utilization analysis
- Provider risk assessment
- Claims review
- Documentation sufficiency review
- Improper payment identification
- Fraud, waste, and abuse support
Medical records and claims are evaluated against applicable coverage requirements, payment policies, coding guidance, clinical standards, and program-specific requirements. That disciplined process helps agencies identify documentation deficiencies, payment vulnerabilities, utilization concerns, coding discrepancies, and other issues that may affect program integrity.
Advanced analytics and artificial intelligence support medical review by helping identify high-risk claims, unusual utilization patterns, coding inconsistencies, and documentation gaps. Natural language processing assists reviewers by extracting relevant information from large volumes of clinical documentation. Verve maintains appropriate human oversight throughout, supporting transparency, consistency, and defensibility.
Past performance
Where the work has been done
- Dynamic coding audit and revenue cycle team with more than 25 years of comprehensive experience across federal agencies (CMS and DHA) and private payers
- On-site and remote medical coding training services
- Medical review and validation of claims, including inpatient, outpatient, skilled nursing facilities, office visits, home health, end-stage renal disease care, inpatient rounding professional services, ambulance services, anesthesia services, psychiatry, radiology, surgeries, labs, inpatient and outpatient facility charges, infusions, durable medical equipment (DME), and Medicare Part B drugs and supplies
- Medicare Managed Care Organizations' cost report validation of reported claims
- Medicare Advantage and Prescription Drug Plans' CMS-1500 and CMS-1450 claims
- Accuracy audits of outpatient medical records
- Comprehensive medical review support
Differentiators
Why agencies and payers bring this work to Verve
Certifications
Certified coding and audit professionals (CPMA, CCS, CPC, COC, CRC, RHIA, RHIT, CPCO) and in-house Registered Nurses (RNs), supported by certified financial professionals (CPAs, CFEs).
Regulatory depth
Deep knowledge of federal and payer-specific guidelines, including the CMS and MAC regulatory hierarchy for claim adjudication and medical necessity validation.
EMR and EHR systems
Experienced across different EMR and EHR software environments.
Statistical audit tooling
Experienced in RAT-STATS statistical audit software.
Audit defensibility
Emphasis on accuracy, integrity, and audit defensibility.
Turnaround
Turnaround times aligned with operational and financial goals.
Tailored methodology
Customized audit methodologies based on client risk profiles.
Next step