...Coding Compliance: Practical Strategies for Success by Sue Prophet, RRA, CCS, and Cheryl Hammen, ART -------------------------------------------------------------------------------- "Fraud," "abuse," "upcoding," "unbundling," and "compliance" have all become buzzwords in the news media. Eliminating healthcare fraud and abuse has become a top priority for the federal government. Government investigations are on the rise and providers everywhere tremble at the thought of becoming the next investigative target. An Office of Inspector General (OIG) audit of the Health Care Financing Administration (HCFA) revealed errors in 30 percent of all claims paid by HCFA in fiscal year 1996.1 These errors account for approximately $23.2 billion annually, or 14 percent of total Medicare fee-for-service (i.e., excluding managed care) payments. About half of the errors identified resulted from insufficient or lack of documentation from providers, and one-third of the documentation errors were associated with providers who failed to respond to repeated requests from auditors to submit documentation. The breakdown of the types of errors resulting in the improper payments is as shown in Figure 1. Breakdown by type of provider is shown in Figure 2. Figure 1 Insufficient/No documentation 46.76% Lack of medical necessity 36.78% Incorrect coding 8.53% Nonconverted/ Unallowable service 5.26% Other 2.67% -------------------------------------------------------------------------------- ...
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...Errors in Compliance and Coding April 19, 2013 Errors in Compliance and Coding There's several causes that create billing and coding error in the medical field. One of the biggest errors that are made are typos, billing the same thing and dates that aren't listed on the patient's file. Typos is the most common error that is often done. When you have typos, that creates problems for the patient, doctor and the billing department. One major mistake is in the address and patient's name. Now there's double billing. Codes are used to show certain procedures have been done, but if a patient is doubled billed for the same procedure like a flu shot. The patient had one shot but was charged for two. Another common error in billing and coding is incorrect dates. Incorrect date such as patient's that are in hospital can be listed as staying for three days but was billed for eight days. This is considered to be one of two major problems that's often seen because if a patient is due for surgery on a specific day and was not done until a month later, this is considered a billing error. The only way to fix billing and coding errors are by checking and rechecking the patient's statements before there sent out to the patient. If by chance there is an error on the statement, a letter of apologize can be written in response to the billing and coding error that was made. If there's no return response, contacting the protective office in the state the error was done...
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...Errors in Compliance Coding Double billing, typos, and incorrect dates are among the most common causes of billing and coding errors that can happen. Double billing is when you have a procedure done by your provider and they try to charge you for two procedures. It could also be something as simple as a hospital billing you for taking two pills when you were only given one. Typo’s are another common billing and coding error, and can be found in the patients name or address. The last is incorrect dates entered into the file. It could be that you stayed in the hospital for four days but the hospital has you listed as staying for seven days and they end up charging you for those seven days. Solutions for the coding and billing errors are to make sure you double check your statements when they come in to make all the information is correct. If a mistake is found, you need to write a detailed letter and send it to the facility or to a patient representative to make sure the error is corrected. The Medicare National Correct Coding Initiative (CCI) controls improper coding that would lead to inappropriate payment for Medicare claims. CCI has coding policies in place that are based on the coding conventions in CPT, Medicare’s national and local coverage and payment policies, National medical societies coding guidelines, and Medicare’s analysis of standard medical and surgical practice. CCI has thousands of CPT code combinations that are by computers to check claims in the Medicare...
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...Anywhere Hospital Coding Compliance Plan. The missing elements of the Coding Compliance Plan include: applicable reporting requirements required by specific agencies; areas of risk that have been identified through audits or monitoring; a process for coding new procedures or unusual diagnoses; a procedure for processing claim rejections; the use of and reliance on encoders within the organization; and a reference to the AHIMA Standards of Ethical Coding. A Coding Compliance Plan needs to have all the recommended subjects covered to ensure compliance with coding protocol. Coding Compliances Plans should include applicable reporting requirements required by specific agencies. Policies and procedures are used to direct staff on how different matters should be handled, therefore, having information on reporting requirements for specific agencies will assist coders as well as other...
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...Compliance and Coding Management Task 2 Western Governor’s University Compliance and Coding Management Task 2 A. Outline a HIM compliance plan that emphasizes the coding function by doing the following: 1. The necessary components of a compliance plan include Code of conduct, policies and procedures, education and training, communication, auditing, corrective action and reporting. The code of conduct is a statement or oath that establishes the intent to perform duties lawfully and ethically. The second component of a plan would include policies and procedures. The policies and procedures for coding would cover items such as how and when to query a physician, acceptable documentation sources, how to rebill a claim, usage of coding guidelines, payer specific issues, and any additional gray areas that may arise in the coding function. Education and training processes must also be outlined in a HIM compliance plan. This would need to identify the number of mandatory CEU’s for each employee, new hire training guidance and requirements, as well as physician and clinical staff educational guidelines and processes. The HIM/Coding compliance plan should also include policies and procedures that address communication, the auditing/monitoring process, any necessary corrective action steps and finally the process for reporting the coding compliance steps that have been followed and any areas identified as risks or any findings of noncompliance. 2. The HIM director...
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...Analyze the various job functions of the current staff. Coders A coder is an individual that examines patient medical records and finds any diagnoses, treatments/medicines given, diagnostic testing, and so forth and gives each of these incidences a numerical (sometimes alphanumeric) value that is universal across insurance companies to collect payment for services rendered. Inpatient Coder- An inpatient coder is an individual that initiates requests for payments and reimbursement for procedures performed on a patient during a hospital stay on behalf of the medical facility. Inpatient Coders will deal more with ICD-9(10) or Diagnosis Codes than with CPT Procedure Codes. Inpatient coding could be considered to be more complex than outpatient coding because of the vast possibilities of different diseases, encounters and procedures. Outpatient Coder- An outpatient coder is an indiviual that initiates requests for payments for procedures performed either in a doctor's office or hospital outpatient department. Any procedure performed that does not require for the patient to stay more than 24 hours is considered outpatient. Outpatient coders typically deal more with CPT Procedure codes versus ICD 9(10) Diagnosis Codes. Outpatient coders that operate within doctor's offices are usually exposed to the same codes on a regular basis which is why many inpatient coders start off in an outpatient setting. Front Office Clerk The front office clerk is a job title that can differ in many...
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...Healthcare Compliance and Coding Management Task 1 A. Discuss how you would carry out your various responsibilities as a coding manager by doing the following: A1. Analyze the job description for an inpatient coding position Managers should be aware of skill sets needed for an HIIM workforce, and recruit qualified staff to fulfill new job roles. Manager should review the job description each time they have a recruitment opportunity. They need to ensure the description outlines the work to be performed. It should be specific to the role of Inpatient Coder. The job description needs to include the position requirements, purpose, and all functions. It should also list the qualifications needed to be hired and successful. Sections of the description should also include education level, years of experience, specific knowledge needed, and any specific proficiency needed for the job. Be specific, before posting a job. Specification helps to minimize the wasted time and effort of the interviewer and interviewee. One of the Inpatient coder’s responsibilities would be reviewing all patient files for accuracy and recording into the computer; therefore a couple of key qualifications that should be listed would be, attention to detail and has medical terminology background. (Wilson, Jacqueline) Job descriptions are used by the manager to clearly set employee expectations for job performance. A2. Develop goals for a clinical documentation...
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...The given “Healthcare Compliance and Coding Management Effectiveness Scenario” describes the day to day challenges that a Health Information Management (HIM) department Manager/Supervisor will face. In this case it is actually a newly hired HIM department’s Manager/Supervisor. My approach to address the challenges presented in the scenario would be to first access and analyze the current workforce that I am responsible to manage, evaluate the new requirement that has to be fulfilled as a result of acquisition of the new clinic, and finally make decisions based on the qualifications, standards and requirements of the required workforce, taking into account the productivity and quality of work at both the hospital and the newly acquired clinic. In the given scenario there is currently a rural hospital and an outpatient setting. Apart from these 2, the organization has also acquired an outpatient clinical setting 50 miles from the hospital which has contracted a local lumberyard and small farm equipment manufacturing plant in town to provide medical services for injured workers. In the hospital setting there are 3 coders who take care of inpatient coding services, one front office employee who takes care of the paperwork, phone calls, release of information, and filling and retrieving of health records from various hospital departments. One of the coders also performs coding services for the outpatient setting that is attached to the hospital. In the newly acquired outpatient clinical...
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...Other than the methods discussed above, there are few other methods can be applied under the grounded theory such as open coding, axial coding, selective coding, memoing, sorting, writing and many others.For our research purpose as stated by Holy Feen we will be only looking at the first three methods. The first method is known as open coding. Open coding is carried out by analysing a research by identifying, naming, categorizing and describing a phenomena found in the text. The only way for us to analyse a research is by going through each line and paragraph and also reading and re-reading in search of the answer by questioning ourselves 'what is the objective about?' or 'what is being referenced in that particular line?'. These categories may consist...
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...Thomas WILLIAMS – service record extracted from Muster Rolls of 20th Foot regiment 1812 May Active in Newry “Volunteer from Royal Westminster Militia paid by them to 6th May” (as a private) June Active in Newry July “From Private” (to Drummer on 25th). “Sent recruiting To Bungay, Suffolk, Eng paid by me to 25th” August Recruiting in Bungay September Recruiting in Bungay October In red: “Cordwainer at St George, Middlesex” November Recruiting in Bungay December “To recruiting company” 1813 January Recruiting in Bungay February Recruiting in Bungay March Recruiting in Bungay April Recruiting in Bungay May Recruiting in Bungay June Recruiting in Bungay July Recruiting in Bungay August Recruiting in Bungay September Recruiting in Bungay October Recruiting in Stowmarket November Recruiting in Stowmarket December Recruiting in Stowmarket 1814 January Recruiting in Stowmarket (Regiment shown as being in Totnes) February Recruiting in Stowmarket March Recruiting in Stowmarket April Recruiting in Stowmarket May Recruiting in Stowmarket June Recruiting in Stowmarket July Recruiting in Stowmarket “The regiment being at home this manning will be discontinued on the rolls from 25th July” (home depot = Knightsbridge) August Recruiting in Stowmarket (Regiment shown as ‘on ship’) September Recruiting in Stowmarket October Recruiting...
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...PROBLEM FORMULATION 3.1 Problem Statement Low density parity check codes are forward error correcting codes. The LDPC block codes are inefficient, since a new code must be hypothesized each time a change in frame size is desired. A number of algorithms with varying complexity and performance have been proposed for LDPC decoding. But achieving a balanced trade-off between decoding performance and implementation complexity still remains a potential problem. LDPC decoding algorithms operates by making either hard decision or soft decision on the message received from the noisy channel [20]. 3.1.1 Sum product Algorithm The sum product algorithm for LDPC decoding is a soft decision message passing algorithm. In case of soft decision based algorithms, the input data to the decoder is the channel probabilities, represented in logarithmic ratio which is known as log-likelihood ratio (LLR). This algorithm requires LLR for variable node operations to make decoding decisions. The LLRs are transferred over to the variable nodes (V), this variable node carry out the sum operation on the input LLRs as in equation (1) and computed messages are passed along the connected edges to the check nodes (C). SPA Variable node operation: V_i=〖LLR〗_n+∑_(j≠i)▒C_j (1) Where n=1,2,. . . .number of variable nodes i, j=1,2,. . . .degree of variable node The operation performed by the check nodes (C) is given in equation (2). The check nodes also perform...
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...________________________________________________________________ LINEAR BLOCK CODES A systematic (n,k) linear block code is a mapping from a k-dimensional message vector to an ndimensional codeword in such a way that part of the sequence generated coincides with the k message digits. The difference (n − k) represents the parity bits. A systematic linear block will have a [k × n] generator matrix [G] of the form G=[P IK ] Then the code is given as C= D*G Where D is the data word. Another important matrix associated with block codes is the [(n − k) × n] parity check matrix, [H]. The parity check matrix is formed by starting with the identity matrix and appending the transpose of the nonidentity portion of [G]: H=[IK PT ] The parity check matrix has the property c[H]T = 0 That is, any errorless, received code word multiplied by the transpose of the parity check matrix, [H], yields a zero vector, or syndrome. If the received code word contains an error, the resulting vector will match the corresponding bit that caused the error. S= R[H]T=E H]T Where S= error syndrome R= received codeword E=error Algorithm: 1. Take generator matrix from the user. 2. Create the 4 bit data word, total of 16 data words, using two dimensional array in the matlab. 3. Then code word is generated utilizing the matrix multiplication formula for the code word. 4. Then Hamming distance...
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...Coding Theory 8/12/15 Coding theory is a study of codes it is generally used in error correcting codes ad error detecting codes. It is way to have a secured application or network in today’s generation where the technology and information is growing rapidly. How coding theory works is for example we have lots of information and we want to decode it. Error detecting will detect all the errors in the information and error correcting will fix al the errors but most of the time it can we difficult to correct the errors when they are detected. Coding theory has many techniques different like hamming codes, perfect codes and generator matrices these are few techniques that work with coding theory. Error detecting codes helps look for errors in information or codes and it lists all the errors in the codes. Since most of the technology we use are binary numbers of 0’s and 1’s error detecting codes uses these binary numbers to look for the errors in codes. Some of the things like digital messages and zip code use error detecting to find any error like if there is a wrong zip code entered. Error correcting codes include error detecting codes so it can detect errors and also fix the errors. What exactly error correcting does is for example if we send some data to someone. Error correcting will fix all the errors it has detected while it is getting all the information. Hamming distance measures the length of the character from one to another mostly two binary strings or...
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...6． Durham: https://www.dur.ac.uk/study/postgraduate/taught/ 6. St Andrews: http://www.st-andrews.ac.uk/media/pgdegrees11-12.pdf 8. Warwick: http://www2.warwick.ac.uk/study/postgraduate/courses/coursea2z/#p 9. Lancaster: https://www.postgraduate.lancs.ac.uk/PGSearch.aspx 10. Exeter: http://www.exeter.ac.uk/postgraduate/degrees/taughtindexa/ 11. York: http://www.york.ac.uk/study/postgraduate/courses/ 12. Bath: http://www.bath.ac.uk/management/courses/postgraduate/ 13. Bristol: http://www.bristol.ac.uk/efm/postgraduate-programmes/ 14. Sussex: http://www.sussex.ac.uk/study/pg/2012/taught#a 15.Edinburgh: http://www.ed.ac.uk/studying/postgraduate/degrees?taught=Y&cw_xml=subjectarea.php 16.Nottingham No business http://pgstudy.nottingham.ac.uk/postgraduate-courses/schools-and-departments.aspx 17. Sheffield: http://www.sheffield.ac.uk/postgraduate/taught/courses/all 17. Leicester: http://www2.le.ac.uk/study/postgrad/taught-campus 19. Southampton: http://www.soton.ac.uk/postgraduate/pgstudy/programmes/index.html 20. Loughborough: http://www.lboro.ac.uk/study/postgraduate/courses/#p 21. Buckingham: http://www.buckingham.ac.uk/courses/ 22. Glasgow: http://www.gla.ac.uk/postgraduate/ 25. Newcastle: http://www.ncl.ac.uk/postgraduate/search/list/courses/taught 27. East Anglia: http://business.uea.ac.uk/courses 28.RoyalHolloway: http://www.rhul.ac.uk/studyhere/postgraduate/departmentsandcourses.aspx ...
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...A. Compliance Status The following executive summary focuses not only on the identified gaps in the current process, but also the corrective action plan to support compliance in the noted areas of the Communications Standards as provided by The Joint Commission, (National Patient Safety Goals, 2013). The high risk associated with surgical procedures performed on the wrong site has driven a risk mitigating approach to the processes involved for these procedures. The goal is to prevent harm to patients having a surgical procedure. The following summary is the current compliance status if the Priority Focus Area of Communication for Nightingale Community Hospital. After review of the specific areas identified in the Priority Focus Area, the following have been identified as requiring further attention: time-outs are routinely performed prior to every procedure (UP 01.03.01) and procedure site is marked (UP 01.02.01). Based on the evaluation of the Nightingale Community Hospital National Patient Safety Goals for Communications the current compliance rate related to the Universal Protocol Time-Out processes performed hospital wide indicate a 95% to 100% compliance rate for the year. The graph provided in the Nightingale Community Hospital National Patient Safety Goals Communication assessment provides limited information as these are hospital wide percentages. No unit specific evaluations of performance have been provided in the report. Upon review of the Site Identification and...
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