The compliance process is very important in medical billing and coding. After a patient is seen, physicians document the patient’s visit. Medical administrators then post the medical codes of the visit in the practice management program (PMP) and prepare the claim. It is important to prepare claims correctly in order to stay in compliance. A correct claim connects a billed service to a diagnosis. The diagnosis has to relate to the billed service to treat the patient’s ailment. The connection is referred to as code linkage.
It is important to correctly link procedures and diagnosis’ because if they aren’t correctly link the payer will reject the claim and will not pay for the services which then makes the patient responsible for payment. To be in compliance, medical insurance specialists need to know each payer’s billing rules stated in each insurance policy. These are subject to change and updated frequently so medical insurance specialists also use payer bulletins, websites, and maintain communication with payer representatives to make sure they are staying in compliance.
Medicare also has its own set of rules and regulations. The Medicare National correct coding initiative (CCI) controls improper coding. CCI edits are used by computers to check claims for errors that would lead to improper payment of services. The CCI prevents two procedures from being billed that could not have been performed together. Private payers also have code edits similar to the CCI.
Compliance errors sometimes occur. Submitting an improper claim may just be a simple mistake such as a typo, or sometimes it may be a deliberate act of fraud. Other common errors that are sometimes made are truncated coding, incorrect gender or age of the patient, assumption coding, altering documentation, coding without proper documentation, reporting services provided by unlicensed providers, and coding a unilateral service twice instead of choosing the bilateral code. For these reasons there are several billing and coding compliance strategies that have been put in place.
One compliance strategy used by healthcare professionals is to carefully define bundled code and know global periods. A medical insurance specialist needs to be clear on what individual procedures are contained in bundled codes and what the global periods are for surgical procedures. Another strategy is to benchmark the practices E/M codes with national average. By comparing the practice reports with national averages, upcoding is able to be monitored. Another strategy is to use modifiers appropriately, and be clear on professional courtesy and discounts to uninsured and low income patients.
The strategy that I find the most useful and am in support of is to maintain compliant job reference aids and documentation templates. Job reference aids are a form of a cheat sheet that lists procedures and CPT codes that are most often used by each individual practice. I think that the only way this strategy can be improved is to make sure that the job reference aids are updated frequently when new services are added to the practice, and when codes change or new ones are added. This can be accomplished by keeping track of when codes are updated or changed.
There are many implications of incorrect medical coding. An improper claim will get rejected or denied by the payer. When this happens the physician will need to either file an appeal, or correct the issue. If the error can be corrected the claim can be resubmitted, however this is still unfortunate because the process will take longer than if it had been done right in the first place. When coding errors are made due to fraudulent attempts, the person who prepared the claim will lose their job and face legal action. Also, sometimes the physician in charge of the practice will be liable and possibly sued, because he/she is responsible for their employee’s and their actions.
Medical coding, physician, and payer fees are all related to the compliance process. Any services performed by a physician will need to be correctly coded so that they can be paid for. Medical coding must be done properly in order to stay in compliance. Physicians must be honest and provide proper documentation of any and all services performed in order for an insurance company to accept a claim and pay for the services that were performed. As long as everyone works as a team, and works in honesty, it is easy to stay in compliance. And by using the strategies I have outlined, compliance is not difficult to follow.