Evaluating Compliance Strategies

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Evaluating Compliance in Coding
By: Terry Valencia
Axia College of University of Phoenix
Billing and Coding compliance strategies protect physicians from financial risk and potential loss of revenues. Physicians must document fully the service they provide and put in force a plan that prevent or reduce coding errors. According to, “The Journal of the National Medical Association,” there are 10 top billing concerns for physicians: Medicare billing (Part A and Part B)

Mental health billing.
Self-Referring to entities where the physician has a financial interest. Billing for services provided at certain stat[-owned sites (i.e., prisons). Not differentiating between out patient clinic and physician office visits. Improper use of “25” modifier use with E & M codes for day surgery. Not returning over payment to medicare immediately.

Billing multiple anesthesiology services at individual not concurrent rates. Billing critical care by the hour, not by documented patient care. Upcoding by billing service companies on behalf of the physician. When filing claims appropriate codes on all levels of service provided must be documented. To avoid any fraudulent activities, a plan must be implemented that created sufficient and effecting guidelines which would ensure coding is within federal, state, and local laws. Not applying the appropriate code can go unrecognized, that is why updating and ensuring coding standards are current is such an important part of the coding process. Physicians that choose regularly to use higher level codes, when a lower level is required is participants of upcoding. OIG and other agencies will investigate and determine if such fraudulent activity has occurred and possible reprimands will be enforced, including jail time. OIG, federal and local laws prevent abuse when filing claims. The OIG list the following high risk factors for physicians: Billing for items or services not provided.

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