1. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

2. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

3. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

4. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

5. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

6. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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”

7. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

8. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

9. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

10. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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?

11. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

12. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

13. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

14. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

15. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

16. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

17. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

18. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

19. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

20. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

21. Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

22. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

23. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

24. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

25. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

26. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

27. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

28. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

29. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

30. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

31. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

32. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

33. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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

34. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.

35. Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 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.