Chapter 7 Visit Charges & Compliant Billing

1. Chapter 7Visit Charges & Compliant Billing OT 232 OT 232 Ch 7 lecture 1

2. Compliant Billing • C0mpliance? • Actions that satisfy official guidelines & requirements • Correct claims report the connection between a billed service & diagnosis • Code linkage • A clean claim will get the maximum amount of money in fast with no additional work • Consequences of non-compliance? • Box on 207 OT 232 Ch 7 lecture 1

3. Knowledge of Billing Rules • Must keep up-t0-date! • Insurance companies have bulletins, websites, etc. • Easier in a specialized office because less to track OT 232 Ch 7 lecture 1

4. Medicare Regulations:The Correct Coding Initiative • CCI • National policy on correct coding • Come from CMS • Controls improper coding that would lead to inappropriate payment • Updated quarterly • Has thousands of code combos called CCI edits that check claims via computers • Apply to claims that bill for more than one procedure for the same patient on the same day by same provider OT 232 Ch 7 lecture 1

5. CCI (cont’d.) • Also tests for unbundling • Incorrect billing practice of breaking a package of services into component parts & reporting them separately • Requires physicians to report only the more extensive version of the procedure performed OT 232 Ch 7 lecture 1

6. Organization of CCI edits • Column 1/Column 2 Code Pairs • Checks for unbundling • Col 1 includes all services described by Col 2 • Medicare pays for Col 1 • Software available to help check beforehand (Billing Tip, pg 211) • Ex pg 209 OT 232 Ch 7 lecture 1

7. Organization of CCI edits (cont’d.) • Mutually Exclusive Code Edits • MEC • Also uses 2 columns • Cannot be billed together • Medicare pays lower-paid • Ex pg 210 OT 232 Ch 7 lecture 1

8. Organization of CCI edits (cont’d.) • Modifier Indicators • Control modifier use to avoid CCI edits • Modifiers show particular circumstances related to a code on a claim • 1 – modifier may be used for special circumstance • Adjudicator will assess • 0 – no deal • 9 – original edit was a mistake; resubmit for payment if appropriate • Ex pg 211 OT 232 Ch 7 lecture 1

9. Medically Unlikely Edits • MUEs • Unit-of-service edits that check for clerical or software-based coding or billing errors • Established by CMS to reduce error rates • Initial set is based on anatomical considerations • Hysterectomy on a male • Will also reject billings in excess of Medicare allowances OT 232 Ch 7 lecture 1

10. Other Government Billing Regulations • The OIG Work Plan • Issued annually as part of Medicare Fraud and Abuse Initiative • Lists projects for sampling particular types of billing to determine whether there are problems. Practices then study these to make sure their procedures comply with regulations • OIG also issues advisory opinions • Legal advice to parties that ask specific questions • If the asking party follows the advice, they cannot be investigated on the matter • Good for others to read • OIG also summarizes findings after investigations & publishes the LEIE • List of Excluded Individuals/Entities • Have been found guilty of fraud and are now excluded from work with government programs • Knowingly hiring excluded companies/people is illegal OT 232 Ch 7 lecture 1

11. Private Payer Regulations • CCI edits apply to Medicare claims only • Private payers will develop their own edits • May or may not share them • Will have to call for clarification • HIPAA Tip – pg 212 OT 232 Ch 7 lecture 2

12. Compliance Errors • Payers often base their decisions to pay or deny claims only on the diagnosis and procedure codes • Refers to ‘code linkage’ • The doctor must justify the procedure • Most payers will have edits to check for this • ‘Medical Necessity’ will vary by payer OT 232 Ch 7 lecture 2

13. Errors relating to Code Linkage & Medical Necessity • Codes that meet medical necessity generally meet these conditions • The CPT procedure codes match the ICD9 diagnosis codes • The procedures are not elective, experimental, or nonessential • Criteria varies by payer • The procedures are furnished at an appropriate level OT 232 Ch 7 lecture 2

14. Errors relating to the Coding Process • Truncated coding • SPECIFICITY!!! • Billing tip, pg 213 • Gender/age mismatch • Assumption coding, altering documentation after services are reported, coding w/out proper documentation • Reporting services provided by unlicensed or unqualified personnel • Not satisfying the conditions of coverage of a particular service OT 232 Ch 7 lecture 2

15. Errors related to the Billing Process • Billing noncovered services • If in doubt, look it up in the Schedule of Benefits • Unbundling • Billing a consultation instead of an office visit • Billing outdated codes • ‘Upcoding’ or ‘downcoding’ • Billing without signatures OT 232 Ch 7 lecture 2

16. Strategies for Compliance • Carefully define bundled codes and know global periods • Amount of time during which all services related to a surgical procedure are considered part of the package and not additionally reimbursed • Benchmark the Practice’s E/M codes with National Averages • Evaluation and management • Procedure codes that cover physicians’ services performed to determine the optimum course for patient care OT 232 Ch 7 lecture 2