qwertyuiopasdfghjklzxcvbnmqw

ertyuiopasdfghjklzxcvbnmqwert
yuiopasdfghjklzxcvbnmqwertyui
opasdfghjklzxcvbnmqwertyuiopa
Evaluating Compliance.
HCR 220
sdfghjklzxcvbnmqwertyuiopasdf
ghjklzxcvbnmqwertyuiopasdfghj
klzxcvbnmqwertyuiopasdfghjklz
By: Shonelle Best

xcvbnmqwertyuiopasdfghjklzxcv
bnmqwertyuiopasdfghjklzxcvbn
mqwertyuiopasdfghjklzxcvbnmq
wertyuiopasdfghjklzxcvbnmqwe
rtyuiopasdfghjklzxcvbnmqwerty
uiopasdfghjklzxcvbnmqwertyuio
pasdfghjklzxcvbnmqwertyuiopas
dfghjklzxcvbnmqwertyuiopasdfg
hjklzxcvbnmqwertyuiopasdfghjk
Evaluating Compliance

Evaluating Compliance Strategies

There are many ways to comply with the strategies of billing and coding.   The

compliance laws are in effect to protect everyone involved.   Compliant billing is very

difficult at times but, when you follow the compliance rules it makes the process a lot

easier.

The first step would be to know your bundle codes. Bundle codes have several

different things that are covered rolled up into one code. There are also what is called

global periods which are used for surgical procedures, know what these codes cover.  

Most places follow the Medicare’s CCI list for both the bundling and the global periods.

There are other list but if the other list is going to be used make sure you are aware of

exactly what is covered in each area. There are modifiers used at one point or another

in every billing that is done.   Make sure they are being used correctly.   When modifiers

are done it eliminates the impression that one is trying to duplicate billings.  

There are certain modifiers that are important for the compliant billing, make sure

you know what these are.   For instance modifier -25 :Significant, Separately Identifiable

Evaluation and Management(E/M) Service by the Same Physician on the Same Day of

the Procedure or Other Service.   This code is used when a patient has some sort of

evaluation done; when the code is used it is clearly stating the doctor done a completely

different procedure on the same day.

There are a few other codes that are used a lot in the coding process; modifier

59; Distinct Procedural Service which is used one is coding a procedure that is

independent from any other services that were performed on the same day.   Modifier
-91; Repeat Clinical Laboratory Test is a code that is used with any laboratory

procedure or if the patient has to have some type of a repeat test or procedure.   These

are a few of the most common modifiers but there are many others.

First among the strategies for compliance is defining bundled codes and knowing

global periods. This step requires that the medical biller knows what procedures are

involved in certain code bundles in order to keep from unbundling them. It suggests that

the medical biller should become familiar with Medicare’s CCI list of bundling rules, as it

is the most widely used set of rules on such procedures. It also says that if the payer

has a unique set of codes, the medical biller must have access to such codes.   This

step works and has been used for years, but it is, and can be, very confusing. There are

many different sets of codes that are used depending on who the payer is. Another

problem that could result from this is that some of the code swapping could make it hard

to link diagnoses with procedures. This is important because payers analyze this to see

if charges are appropriate, or medically necessary. It is also important to do this

because if a patient is diagnosed with a specific heart problem and then they receive

anesthesia, this could cause a serious problem. Mixing codes from different payers

could become a serious.

The compliance process is set up to ensure the maximum appropriate

reimbursement for health care claims. Correct billing and coding are directly linked to

correct documentation by a physician.  Also, to complete documentation, linking the

correct code to the correct diagnoses is a must. This step is vitally important in reducing

compliance errors. Second, the implications of incorrect coding can have a domino

effect and will ultimately cause many people in the chain of events to go back, review,
correct the errors, and resubmit the claim. This could also cause the patient and payer

more money or cause a claim to be denied. Additionally, medical coding, physician,

and payer fees are connected because they affect how much a payer will cover, a

patient will pay, and how much a practice will charge for services. Physician and payer

fees are both built on different systems that allow for the determination of the cost for

procedures and services. In the end, this will determine what a patient will have to pay.

A combination of correct and thorough documentation by the physician, correct coding,

and complete compliance with billing regulations will ultimately reduce errors and

ensure that providers, payers, and patients will be billed and reimbursed properly.

The Medicare National Correct Coding Initiative (CCI) is designed to control

improper coding and avoid inappropriate payment for Medicare claims.   CCI updates

the system quarterly and uses thousands of CPT code combinations, called CCI edits,

to check all claims for potential coding or billing errors. CCI edits apply to claims that bill

for more than one procedure on the same day and by the same provider.   CCI edits

work with all Medicare computers to scan for claims that do not pass an edit and will

therefore be denied.   Such situations, like double billing, might happen if a claim is

processed.

To wrap it all up, there are plenty of situations that could have the patient at the

wrong end of a situation and cause them problems, that is why it is wise that a person

should always double check and really pay attention to what is going on with their

Medical Billing and what the doctor’s office is doing, because they also make mistakes.