Chapter 6 Visit Charges and Compliant Billing Compliant

Chapter 6 Visit Charges and Compliant Billing

Compliant Billing Following guidelines for correct coding Code Linkage Necessary Treatments

Correct Coding Initiative (CCI) Control improper coding/improper payments from Medicare Quarterly code edits – system that checks codes Same procedure, same day, same provider Multiple DME from same provider, same day Medicare billing

Office of Inspector General OIG work plan Fraud and abuse initiative Check compliance with billing regulations Government Payers

Private Payer Regulations Similar to CCI Regulations found in contracts, handbooks, and bulletins

ERRORS!!!! Linkage and Necessity Truncated or assumption coding Billing for Noncovered services Separate codes (unbundling) Invalid or outdated codes Upcoding or Downcoding

Thinking It Through Botox injections have been approved by the FDA as a procedure to treat spasms of the flexor muscles in the elbow, wrist and fingers. Should a payer reject a claim for this use of Botox based on lack of medical necessity?

Staying Compliant Know global periods and what is included in packaged codes How many postop days are part of the global package? Compare E/M codes with National averages Use of modifiers Know professional courtesy guidelines Stay educated and up to date

Audits Formal review External—by payers Prepayment audits Postpayment audits Internal—by medical office Is coding being done properly?

E/M Audits CMS/AMA Documentation Guidelines for Evaluation and Management Tool used to reduce subjectivity in assigning level of service Clear examples and descriptions to fit in each category

Selecting a Code (pp. 210 -213) History of Present Illness Ø Ø Ø Ø Location Quality of pain Severity Duration Timing Context Modifying Factors Associating signs and symptoms 1 -3 = Problem Focus 4 -8 = Extended

Physician Fees Usual fees Fee Schedules UCR Usual, customary, reasonable RVS Relative value scale RBRVS Resource-based relative value scale

Fee-based Systems Allowable Charge by Payer Maximum charge Allowed amount Contract adjustments Patient responsibility is based on allowed amounts when going to a PAR provider Coinsurances are based on allowed charges

Bundled Payments with Healthcare Reform

Capitation Setting cap rates Demographic of patients and number of visits expected Type of practice (Pediatrics, OBGYN, GP) Prepaid monthly payment Agreed upon covered services (office visits, but not surgery)

Collecting TOS Payments Depends No on third-party agreement collection for Medicaid or Workers’ Comp Payment expectations need to be communicated when a patient signs up to be a new patient.