Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. HaynesComprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

Chapter 7HCPCS and Coding Compliance

Comprehensive Health Insurance: Billing, Coding, and ReimbursementDeborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes

Level I codes and CPT codes are the same.

Level II codes represent codes that are not found in the CPT or ICD-9-CM, such as medical equipment and supplies.

Level III codes are assigned and maintained by individual state Medicare carriers for new procedures.


Provide standardized coding system managed by private and public insurers

Supplies a predictable set of uniform codes

Provide a stable environment for claims submission and processing


Two-digit codes, alpha or alphanumeric, ranging from AA to VP

Used to modify procedures or services on health insurance forms for Medicare patients

Level III (local) modifiers assigned by individual Medicare carriers


Diagnosis and procedure code connection

Evaluation of medical necessity of reported charges

Regulations cover place, frequency, or level of services


Denied claims Delays in processing and receiving

payments Reduced payments Fines and other sanctions including

prison sentences Exclusion from payer’s programs and

loss of provider’s medical license


Avoids fraudulent claims by ensuring that documentation is complete and accurate.

Compliant claims are an indication of compliant practice.


Is the coded service billable? Is it appropriate to patient’s profile? Is there a clear and correct link to each

diagnosis and procedure? Is the documentation accurate and

supportive? Are reported services compliant with

regulations?


False claims act includes liability for submitting fraudulent claims.

Protection and rewards are available for “whistle blowers.”

Stark Law regarding physician self-referral may represent a conflict of interest.


Civil law maximum penalty is $10,000 per item or service for medical fraud.

Criminal law jail sentences are up to 10 years, in addition to fines.

Administrative law excludes from participation as providers in government health programs.


OIG work plan lists the year’s planned projects for sampling types of billing, checking for problems.

OIG fraud alerts posted on CMS website and issued periodically alert providers to problematic areas.


MOS must comply with all governmental regulations.

Consequences of inaccurate coding include delayed or denied payments and suspicion of fraud.

Compliance programs optimize processing and payment speed and reduce errors.


CPT procedure codes do not match the ICD-9-CM diagnosis codes.

Procedures must not be elective, experimental, or nonessential.

Procedures are not furnished at appropriate level or provided by unlicensed or unqualified personnel.


Include assumption coding or coding without proper documentation.

Include alteration of documentation after services reported or incomplete documentation at the time of billing.

Include upcoding, unbundling, or using modifiers incorrectly


Controls improper coding by standardizing bundled codes.

Edits are comprised of code combinations used in computerized screening process.


Includes comprehensive versus component edits, mutually exclusive edits, and modifier indicators.

Advisory opinions provide legal advice on any question regarding healthcare business.


The medical office specialist is responsible for coding.

Patient confidentiality is a patient’s right and must be safeguarded.


Medical office specialist is an emissary and educator in teaching and implementing correct coding strategies.

Use problem resolution with open dialogue; don’t become part of the problem.

Documents

Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes