Evaluating Compliance Strategies

The compliance process is set up to ensure the maximum appropriate reimbursement for health care claims. Correct billing and coding are directly linked to correct documentation by a physician. Also, to complete documentation, linking the correct code to the correct diagnoses is a must. This step is vitally important in reducing compliance errors. Second, the implications of incorrect coding can have a domino effect and will ultimately cause many people in the chain of events to go back, review, correct the errors, and resubmit the claim. This could also cause the patient and payer more money or cause a claim to be denied.

Additionally, medical coding, physician, and payer fees are connected because they affect how much a payer will cover, a patient will pay, and how much a practice will charge for services. Physician and payer fees are both built on different systems that allow for the determination of the cost for procedures and services. In the end, this will determine what a patient will have to pay. A combination of correct and thorough documentation by the physician, correct coding, and complete compliance with billing regulations will ultimately reduce errors and ensure that providers, payers, and patients will be billed and reimbursed properly.

The Medicare National Correct Coding Initiative (CCI) is designed to control improper coding and avoid inappropriate payment for Medicare claims. CCI updates the system quarterly and uses thousands of CPT code combinations, called CCI edits, to check all claims for potential coding or billing errors. CCI edits apply to claims that bill for more than one procedure on the same day and by the same provider. CCI edits work with all Medicare computers to scan for claims that do not pass an edit and will therefore be denied.

Such situations, like double billing, might happen if a claim is processed where a code is presented for two procedures that, according to Medicare, could not have medically happened. An example would be to code for the removal of an organ by both an incision and laparoscopy. Other than common errors, a situation where a patient is double billed could be caused from not using the correct modifier. Modifiers can easily be referenced and checked to see if one would apply (Valerius, Bayes, Newby, & Seggern, 2008).

CCI edits also scan for unbundling. Codes that are meant to be bundled are grouped together to avoid inputting several codes for common procedures that can be considered one procedure. For example, the removal of the uterus, ovaries, and fallopian tubes can be coded as one code instead of three separate codes. To avoid unbundling, coders should be aware of what procedures are considered bundled codes and what the global periods are for surgical procedures. A global period is the amount of time that is covered for follow-up care.

Billing and coding errors often occur because of double billing, unbundling, and poor documentation (Valerius et al, 2008). Documentation is the next important aspect to billing and coding compliance. Compliance in documentation is important because they serve as a means for physicians to organize their thoughts, justify the treatment, support the diagnoses, and document progress as a result of the treatment. Additionally, documentation provides a continuity of patient care by serving as a channel of communication for caregivers to evaluate, plan, and monitor a patient’s progress and care plans (Micheletti, 2005).

The lack of compliance with physician documentation usually stems from the physician not fully understanding the methodology behind coding and why they are so closely linked together. Education is significant in the aspect that a physician must know what to document, why it is important, and how it will relate to the billing and coding process (Micheletti, 2005). If documentation is done thoroughly and appropriately, then coding compliance will happen with ease and fewer errors will occur. As a coder, it is important to only code what is documented and to remember never to code for a diagnoses that has not yet been made.

If a patient is being seen for chest pain and the doctor is doing tests for a possible heart attack or stroke, it is vital that neither a heart attack nor stroke is coded until an actual diagnosis has been made. The compliance process also includes strategies such as benchmarking the practice’s E/M (evaluation and management) codes with the national averages. This means that any given practice should compare their average codes and billing records to that of national averages to see how close or far the results are from the national results.

Profiling average billing patterns can show compliance and will also help point out practices that might be fraudulent or incompliant. Modifiers also are incorporated with billing compliance because they can eliminate the possibility of duplicate billing or unbundling. They do this by more specifically defining a procedure. Professional courtesy and discounts to uninsured or low-income patients is another way to show compliance with billing and coding. OIG guidelines offer physicians guidance on how much to discount for low-income or uninsured patients.

Many physicians practice professional courtesy because by showing good faith to the patient he or she will be more likely to get paid, if at all. Being clear on professional courtesy is important, however, because what a practice does for one must be done for all. Therefore, being clear on what is discounted and what is not will eliminate room for argument. Another strategy designed to help coders maintain compliance is to provide employees with job reference aids. A job reference aid is similar to a cheat sheet in the sense that it is a quick reference for the most commonly used CPT codes in that particular practice.

If aids are used, it is important that they are dated and current. They should also be updated every year as new codes and updates are released. Also, all CPT E/M codes must contain all the codes in that range. The final strategy would be to do self audits to monitor billing and coding compliance. Establishing a system for monitoring the billing process and performing regular compliance checks is a great way to ensure adherence to established policies and procedures. External audits include private payers or government investigators to review selected records for compliance.

Internal audits are done individually and voluntarily within a practice to reduce errors and show compliance (Valerius et al, 2008). The next major subject in coding compliance is correctly linking the procedure to the diagnoses. Diagnoses and procedures must be correctly linked on healthcare claims for which payers use this information directly to determine the medical necessity of the charges. All codes should be appropriately documented which ties into complete documentation done at the time of the procedure.

If the initial documentation is not done adequately, then a domino effect of incorrect coding will begin to happen (Valerius et al, 2008). This domino effect will ultimately cause the patient or the insurance company to be billed incorrectly, pay loads of money out to procedures that did not happen, or deny claims for procedures that did happen. The outcome will be different for different scenarios, however the one similarity that will consistently happen with incorrect coding is time and money will be wasted.

The final major topic is connecting medical coding, physician, and payer fees and evaluating how they affect one another. Physician fees are established by using “usual fees” for procedures and services that are routinely performed. Usual fees are charges that apply to most of the patients most of the time under normal conditions. Commercial databases exist to show a nationwide list of physician fees for individual practices to refer to when deciding how much to charge for services and procedures. A range of fees are set for different geographical areas.

Then physicians will set fees somewhere along that range by analyzing rates charged by other providers, what government programs pay, and the payments of private carriers (Valerius et al, 2008). Payer fees are established through two main methods. The first method is a charge-based fee structure which is based on what providers with similar training and experience are charging for similar services. The second method is a resource-based fee structure which is construed by comparing three main factors.

The first is how difficult it is for the provider to perform the service. The second factor is how much office overhead the procedure involves and the third factor is the relative risk the procedure presents to the patient and to the provider (Valerius et al, 2008). Once fees are established they will be linked to their respective codes and then billed appropriately. A medical insurance specialist will need to know how to answer questions from patients that concern how much the patient will end up paying and how much his or her insurance will cover.

Knowing how to link medical coding, physician, and payer fees will help a medical insurance specialist be able to answer such questions for patients when they arise. This knowledge will also help explain to a patient why certain charges are different at different practices or how much a patient will be expected to owe after the completion of a procedure. In conclusion, the Medicare National Correct Coding Initiative (CCI) is designed to control improper coding and avoid inappropriate payment for Medicare claims. CCI edits check claims for potential errors.

Billing and coding errors often occur because of double billing, unbundling, and poor documentation. Strategies used to ensure complaint billing include knowledge of bundled codes and global periods, benchmark the practice’s E/M codes with the national average, keep up to date through education, be clear on professional courtesy and discounts, maintain compliant job reference aids, and audit the billing process. Correctly linking diagnoses with procedures will allow payers to use this information directly to determine the medical necessity of the charges, thus allowing everyone in the chain to be billed or paid properly.

Coding procedures and diagnoses correctly the first time is vital for maintaining good compliance and prompt billing or payment. Medical coding is connected to physician and payer fees because they will determine what a payer will cover and what a patient is responsible for. Correct coding will help a medical coding specialist be able to tell a patient at the time of service approximately what a payer will cover and what the patient will have to cover (Valerius et al, 2008). The entire compliance method, in my opinion, is a complex cycle of documentation, codes, and fees.

The cycle may be complex, but it works because it touches every aspect of the medical field and allows for patients, physicians, and payers to work together to provide health care and also to make a living as a business. I support the compliance process in every way and feel there is no room for improvement. I am eager to learn the dynamics that make up the art of medical coding further to help me gain more knowledge about being a good pharmacy technician, and perhaps one day, a medical coding specialist.

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