Chapter 7 Visit Charges & Compliant Billing OT 232 1OT 232 Ch 7 lecture 1

Compliant Billing C0mpliance? – Actions that satisfy official guidelines & requirements Correct claims report the connection between a billed service & diagnosis – Code linkage A clean claim will get the maximum amount of money in fast with no additional work Consequences of non-compliance? – Box on 207 2OT 232 Ch 7 lecture 1

Knowledge of Billing Rules Must keep up-t0-date! – Insurance companies have bulletins, websites, etc. Easier in a specialized office because less to track 3OT 232 Ch 7 lecture 1

Medicare Regulations: The Correct Coding Initiative CCI National policy on correct coding Come from CMS Controls improper coding that would lead to inappropriate payment Updated quarterly Has thousands of code combos called CCI edits that check claims via computers – Apply to claims that bill for more than one procedure for the same patient on the same day by same provider 4OT 232 Ch 7 lecture 1

CCI (cont’d.) Also tests for unbundling – Incorrect billing practice of breaking a package of services into component parts & reporting them separately Requires physicians to report only the more extensive version of the procedure performed 5OT 232 Ch 7 lecture 1

Organization of CCI edits Column 1/Column 2 Code Pairs – Checks for unbundling – Col 1 includes all services described by Col 2 – Medicare pays for Col 1 – Software available to help check beforehand (Billing Tip, pg 211) – Ex pg 209 6OT 232 Ch 7 lecture 1

Organization of CCI edits (cont’d.) Mutually Exclusive Code Edits – MEC – Also uses 2 columns – Cannot be billed together – Medicare pays lower-paid – Ex pg 210 7OT 232 Ch 7 lecture 1

Organization of CCI edits (cont’d.) Modifier Indicators – Control modifier use to avoid CCI edits Modifiers show particular circumstances related to a code on a claim – 1 – modifier may be used for special circumstance Adjudicator will assess – 0 – no deal – 9 – original edit was a mistake; resubmit for payment if appropriate – Ex pg 211 8OT 232 Ch 7 lecture 1

Medically Unlikely Edits MUEs Unit-of-service edits that check for clerical or software-based coding or billing errors Established by CMS to reduce error rates Initial set is based on anatomical considerations – Hysterectomy on a male Will also reject billings in excess of Medicare allowances 9OT 232 Ch 7 lecture 1

Other Government Billing Regulations The OIG Work Plan – Issued annually as part of Medicare Fraud and Abuse Initiative – Lists projects for sampling particular types of billing to determine whether there are problems. Practices then study these to make sure their procedures comply with regulations – OIG also issues advisory opinions Legal advice to parties that ask specific questions – If the asking party follows the advice, they cannot be investigated on the matter – Good for others to read – OIG also summarizes findings after investigations & publishes the LEIE List of Excluded Individuals/Entities – Have been found guilty of fraud and are now excluded from work with government programs – Knowingly hiring excluded companies/people is illegal 10OT 232 Ch 7 lecture 1

Private Payer Regulations CCI edits apply to Medicare claims only Private payers will develop their own edits May or may not share them Will have to call for clarification HIPAA Tip – pg OT 232 Ch 7 lecture 2

Compliance Errors Payers often base their decisions to pay or deny claims only on the diagnosis and procedure codes – Refers to ‘code linkage’ – The doctor must justify the procedure – Most payers will have edits to check for this – ‘Medical Necessity’ will vary by payer 12OT 232 Ch 7 lecture 2

Errors relating to Code Linkage & Medical Necessity Codes that meet medical necessity generally meet these conditions – The CPT procedure codes match the ICD9 diagnosis codes – The procedures are not elective, experimental, or nonessential Criteria varies by payer – The procedures are furnished at an appropriate level 13OT 232 Ch 7 lecture 2

Errors relating to the Coding Process Truncated coding – SPECIFICITY!!! – Billing tip, pg 213 Gender/age mismatch Assumption coding, altering documentation after services are reported, coding w/out proper documentation Reporting services provided by unlicensed or unqualified personnel Not satisfying the conditions of coverage of a particular service 14OT 232 Ch 7 lecture 2

Errors related to the Billing Process Billing noncovered services – If in doubt, look it up in the Schedule of Benefits Unbundling Billing a consultation instead of an office visit Billing outdated codes ‘Upcoding’ or ‘downcoding’ Billing without signatures 15OT 232 Ch 7 lecture 2

Strategies for Compliance Carefully define bundled codes and know global periods – Amount of time during which all services related to a surgical procedure are considered part of the package and not additionally reimbursed Benchmark the Practice’s E/M codes with National Averages – Evaluation and management – Procedure codes that cover physicians’ services performed to determine the optimum course for patient care 16OT 232 Ch 7 lecture 2