Evaluating Compliance Strategies

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Evaluating Compliance Strategies
HCR/220
January 3, 2011
Fonzette Mixon

Evaluating Compliance Strategies
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 where a code is presented for two procedures that, according to Medicare, could not have medically happened. An example would be to code for the removal of an organ by both an incision and laparoscopy. Other than common errors, a situation where a patient is double billed could be caused from not using the correct modifier. Modifiers can easily be referenced and checked to see if one would apply (Valerius, Bayes, Newby, & Seggern, 2008). CCI edits also scan for unbundling. Codes that are meant to be bundled are grouped together to avoid inputting several codes for common procedures that can be considered one procedure. For example, the removal of the uterus, ovaries, and fallopian tubes can be coded as one code instead of three separate codes. To avoid unbundling, coders should be aware of what procedures are considered bundled codes and what the global periods are for surgical procedures. A global period is the amount of time that is covered for follow-up care. Billing and coding errors often occur because of double billing, unbundling, and poor documentation (Valerius et al, 2008). Documentation is the next important aspect to billing and coding compliance. Compliance in documentation is important because they serve as a means for physicians to organize their thoughts, justify the treatment, support the diagnoses, and document progress as a result of the treatment. Additionally, documentation provides a continuity of patient care by serving as a channel of communication for caregivers to evaluate, plan, and monitor a patient’s progress and care plans (Micheletti, 2005). The lack of compliance with physician documentation usually stems from the physician not fully understanding the methodology behind coding and why they are so closely linked together. Education is significant in the aspect that a physician must know what to document, why it is important, and how it will relate to the billing and coding process (Micheletti, 2005). If...
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