Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 7 HCPCS and Coding Compliance
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes HCPCS Codes 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.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Essence of HCPCS Meet operation needs of Medicare and Medicaid Coordinate government programs Allow providers and suppliers to communicate consistently Ensure validity of profiles and fee schedules
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Function of HCPCS 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
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes HCPCS Modifiers 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
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes GA Modifier Used if ABN has been signed by a Medicare beneficiary Denotes a supply or service that may be denied/deemed “not medically necessary”
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Code Linkage Diagnosis and procedure code connection Evaluation of medical necessity of reported charges Regulations cover place, frequency, or level of services
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Consequences of Inaccurate Coding 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
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Accurate Coding Avoids fraudulent claims by ensuring that documentation is complete and accurate. Compliant claims are an indication of compliant practice.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Questions to Ask Prior to Claim Submission 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?
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Federal Law 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.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Government Investigations and Advice 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.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Government Investigations and Advice 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.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Coding Compliance 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.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Coding 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.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Coding Errors 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
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes National Correct Coding Initiative (NCCI) Controls improper coding by standardizing bundled codes. Edits are comprised of code combinations used in computerized screening process.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes National Correct Coding Initiative (NCCI) Includes comprehensive versus component edits, mutually exclusive edits, and modifier indicators. Advisory opinions provide legal advice on any question regarding healthcare business.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Ethics The medical office specialist is responsible for coding. Patient confidentiality is a patient’s right and must be safeguarded.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Ethics 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.
Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 8 Auditing
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Purpose of an Audit Assess completeness and accuracy of documentation supporting the charges. Facilitate high-quality patient care and provide legal documentation of correct billing. Discover lost revenue and prevent future losses.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Top Coding and Documentation Errors Upcoding: Procedure coded is more involved than procedure documented in the chart. Downcoding: Documentation supports a higher code but coder is trying to avoid government investigation.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Top Coding and Documentation Errors Missing or unclear documentation may include chief complaint, diagnoses, tests, medication, or assessment. Encounter form is missing, incomplete, or incorrect. Diagnosis is incorrectly referenced.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Types of Audits Internal audit is done within the practice to ensure correct coding and compliance. External audit is done by private payer’s or government investigator’s review of selected records. Accreditation audit is done by managed care companies to ensure compliance with proper documentation.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Private Payer Regulations Code edits to screen for improper or incorrect reporting of procedure codes. Rules and policies differ among private payers.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Necessity for E/M Services Documentation guidelines Frequency of services Intensity of Services Key components of E/M selection include extent of history, extent of examination, and the extent of medical decision making documented.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Preparing for the Audit Chart selection should include ten to fifteen charts, including new patients, established patients, consultations, encounter forms, and insurance information.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Preparing for the Audit Examine encounter forms to verify completeness. Examine EOBs to determine if billed and reimbursed codes were correct according to documentation.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Key Elements of E/M Services Level of history including chief complaint, history of present illness and past, family and social history Level of examination, either general multisystem or single organ system Complexity of the medical decision making
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Levels of History Problem focused Expanded problem focused Detailed Comprehensive
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Levels of Examination Problem focused Expanded problem focused Detailed Comprehensive
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Levels of Medical Decision Making Straightforward Low complexity Moderate complexity High complexity
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Tips for Preventing Coding Errors with Specific E/M Codes High level services and the “comprehensive codes” require three key components. Physician must re-record or annotate with specific comments any history obtained in order to be paid. Coding subsequent services requires special attention to medical necessity.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Tips for Preventing Coding Errors with Specific E/M Codes See questions regarding consultation on page 203 of the student text. See questions regarding critical care on page 204 of the student text.