Utilization Review

A Retrospective Documentation analysis and/or audit of patient healthcare documentation for quality, integrity, authentication, compliance and medical necessity. 

Pyramed is well versed in the rules and standards related to documentation of health care services. In addition, the issue of medical necessity has become the primary reason for payer and agency audits in an environment that requires documentation to justify clinically appropriate services. Even further, documentation shapes the process of clinical reasoning, and provides the justification for billing and payment for health care services.

Nationally recognized expert in the areas of coding nomenclature, compliance, health care billing Pyramed can provide the following:

  • Assessment of documentation content, format, methodology, and compliance
  • Analysis of documentation integrity 
  • Assessment of practice compliance with state and federal guidelines
  • Education and training 
  • Evaluation of medical necessity
  • Analysis and assessment of current coding applications and associated reimbursement adjustments



  • Assessment of compliance with Medicare rules and regulations 
  • Assessment of compliance with the Medicare Benefit Policy Manual
  • Assessment of appropriate applications of waivers 
  • Assessment of appropriate use of modifiers and review of documentation to support their use
  • Assessment of risk related to Correct Coding Initiative (CCI) and other edit initiatives that affect payment
  • Assessment of compliance with Medicare's Minimal Documentation Requirements



  • Verification and validation of documentation
  • Coding Review (CPT/HCPCS, ICD-9-CM)
  • Utilization Review
  • Comparison of coding distribution with national benchmarks
  • Compliance Audit
  • Charge Assessment (Relative value assessments and comparisons; Fee protocols)
  • Compliance Risk Assessment
  • Data analysis 
  • Charge data and payment history


Hospital / Facility Review

  • Outpatient and Inpatient
  • Compliance Audit
  • Verification and validation of documentation
  • Coding Review (APC / DRG /  CPT / HCPCS / ICD-9-CM)
  • Profile
  • Peer to Peer Comparison
  • Admission History
  • Charge History