Chapter 6 Visit Charges and Compliant Billing

Compliant Billing  Following guidelines for correct coding  Code Linkage  Necessary Treatments

Correct Coding Initiative (CCI)  Control improper coding/improper payments from Medicare  Quarterly code edits – system that checks codes  Same procedure, same day, same provider  Multiple DME from same provider, same day Medicare billing

Office of Inspector General  OIG work plan  Fraud and abuse initiative  Check compliance with billing regulations Government Payers

Private Payer Regulations  Similar to CCI  Regulations found in contracts, handbooks, and bulletins

ERRORS!!!!  Linkage and Necessity  Truncated or assumption coding  Billing for  Noncovered services  Separate codes (unbundling)  Invalid or outdated codes  Upcoding or Downcoding

Thinking It Through Botox injections have been approved by the FDA as a procedure to treat spasms of the flexor muscles in the elbow, wrist and fingers. Should a payer reject a claim for this use of Botox based on lack of medical necessity?

Staying Compliant  Know global periods and what is included in packaged codes  How many postop days are part of the global package?  Compare E/M codes with National averages  Use of modifiers  Know professional courtesy guidelines  Stay educated and up to date

Audits  Formal review  External—by payers  Prepayment audits  Postpayment audits  Internal—by medical office Is coding being done properly?

E/M Audits  CMS/AMA Documentation Guidelines for Evaluation and Management  Tool used to reduce subjectivity in assigning level of service  Clear examples and descriptions to fit in each category

Selecting a Code (pp ) History of Present Illness  Location  Quality of pain  Severity  Duration  Timing  Context  Modifying Factors  Associating signs and symptoms  1-3 = Problem Focus  4-8 = Extended

Physician Fees  Usual fees  Fee Schedules  UCR  Usual, customary, reasonable  RVS  Relative value scale  RBRVS  Resource-based relative value scale

Fee-based Systems  Allowable Charge by Payer  Maximum charge  Allowed amount  Contract adjustments  Patient responsibility is based on allowed amounts when going to a PAR provider  Coinsurances are based on allowed charges

Bundled Payments with Healthcare Reform

Capitation  Setting cap rates  Demographic of patients and number of visits expected  Type of practice (Pediatrics, OBGYN, GP)  Prepaid monthly payment  Agreed upon covered services (office visits, but not surgery)

Collecting TOS Payments  Depends on third-party agreement  No collection for Medicaid or Workers’ Comp  Payment expectations need to be communicated when a patient signs up to be a new patient.