...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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...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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...Evaluating Compliance Strategies Patricia Estrada HCR/220 November 2012 Deborah Ryan Medical billing and compliance strategies are used to bill for medical procedures and treatments. The compliance strategies are in place to prevent incorrect billing, but mistakes are still made. Answers to the importance of correctly linking procedures and diagnoses, the implications of incorrect medical coding, and how medical coding, physicians and payer fees are related to the compliance process will be discussed. It is very important that procedures and diagnosis are correctly linked together. There are certain steps to follow that help to correctly link the procedure to the diagnoses. By following the correct procedures to apply the correct codes that link procedure with diagnosis, insurance companies can be correctly billed for reimbursements. Correctly connected claims can be analyzed and to make sure charges are for medically necessary services provided to the patient. Correct claims help reduce the chance of an investigation of the practice of fraud and the risk of liability in an investigation does occur. (Valerius, J., Bayes, N., Newby, C., & Seggern, J. , 2008). If the procedures are not linked correctly to the diagnoses, then they will not be covered by the insurance company and therefor will not be paid. The major implication of incorrect medical coding would be fraud. Even though incorrect work may simply be an error, it may also represent a deliberate attempt...
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...care field the compliance process is designed to ensure the maximum benefit for health care claims. The compliance process is made up of guidelines set forth by the Health Insurance Portability Accountability Act and by the healthcare staff. These guidelines are setup to protect the physicians, patients, and medical staff. Medical offices can help to reduce errors by making sure that the staff is properly trained and that the office has updated coding and billing software. I think that each office should have a guide that consists of codes which would aid the employees in the billing process. Some offices currently use sheets that are in the front the patients file that contain diagnosis and the codes, which is filled out by the physician. This helps reduce errors in the billing process when the physician completes the code themselves. The Medicare National Correct Coding Initiative is responsible for controlling improper coding and invalid payments for Medicare claims. It is extremely important to correctly link the procedures and diagnoses so that the claim will not be rejected. When claims are rejected due to incorrect linking of the procedures and diagnoses this could result in a loss of money by the physician or the medical facility. When this error occurs claims have to adjusted and then resubmitted, which results in outstanding patient balances due to errors in the medical office. The main implication that occurs form incorrect medical coding is that the medical...
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...Running head: Evaluating Compliance Strategies Assignment: Evaluating Compliance Strategies Name Axia College of University of Phoenix HCR 220 Date “Guidelines established by the healthcare staff and laws established by HIPAA are what make up the compliance process. These laws and guidelines were established to protect the patients, physicians, and staff members” (U.S. Dept. of Health and Human Services, n.d.). Errors in the office can be avoided by having a compliance process in effect. Using updated billing and coding software will help reduce errors made in the billing process. I agree with having a guide consisting of codes to aid in the billing process. I do regard this as cheating rather, to be used as a guide. Many offices currently have sheets that are located on the front of the patients’ file with the diagnosis and the code next to the diagnosis which the physician fills out. This eliminates an unnecessary step in the billing process and is a quicker, easier, and more accurate way to avoid errors. “In order to avoid rejection of the claim, it is important that the diagnoses and procedures are correctly linked” (AAFP, 1999). This also ensures that the claim is paid for the correct procedure performed by the physician. If an incorrect procedure was billed this could result in a loss of money by the physician for the type of procedure that was performed. The claim will have to be adjusted and resubmitted...
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...CheckPoint: Errors and Compliance in Coding HCR 220 CheckPoint: Errors and Compliance in 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 is 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 you statements when they come in to make all the information are correct. If a mistake is found then you need to write a detail 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...
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...Evaluation Compliance Strategies Medical Billing and coding compliance is very important to the billing world. Billing management starts at the first patient contact and ends only when the account has been paid in full. . In between, there are a series of important steps, each of which is critical for accurate billing and proper reimbursement. In this essay we are going to discuss the importance of the linkage code, implications of incorrect medical coding, and how physicians and payers fee are related to the billing compliance. We are also going to discuss what steps we can take to meet the compliance standards. When claims are filed correctly they will show the connection between the service being billed and the diagnosis code. The linkage code helps determine which procedure goes with which diagnosis code. If the linkage codes are not correct this will cause the claim to be denied. Linkage codes help the payer to determine the medical necessity for the service provided. Payers will determine the coverage by medical necessity. Services that are considered to be of nonmedical necessity are not covered under an insurance policy. It is important that the billing specialist be aware that different payers will have their own set of medical necessity edits. The implications of incorrect medical coding can cause issues for both the medical provider and the patient. Coding incorrectly can cause denial of claims. Providers would lose their patients trust, causing them to...
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...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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...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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...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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...#1…Public health IN THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care...
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...Evaluating Compliance Strategies HCR/220 Compliant billing involves certain steps in order to properly bill a patient and receive any monies owed for those services performed. First step is for the doctor to fill out and sign any and all forms at the end of a patient’s visit. The next step is to post the transactions made along with the proper medical codes from a patient’s appointment into the practice management program which leads to the claims being filed. Payers then need to make sure that the services performed along with the diagnosis must show that it was medically necessary services. The billers also need to know the proper rules and guidelines put forth by a patient’s insurance company. Because medical insurance companies constantly change their policies, the insurance specialist rely on the payer’s website or may regular communicate with a representative of the payer. The correct coding initiative controls improper coding that would result in improper payments for Medicare claims. The CCI also monitors billing of any services that Medicare believes cannot be performed together. The CCI also requires doctors to tell about the most extensive service that was performed and not the revealing of both the extensive and limited services. Finally the CCI also tests for unbundling. Many mistakes can be made while billing/coding a patient. Some of those mistakes are: billing invalid/outdated codes, coding without the correct forms, truncated coding; using codes that...
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...important for our employees to take the time to collect as much information as they can from the patient when the patient first presents for service. For the AR plan to work we will need to work with the Human resource and business office manager to implement a training session for all employees that work in admission especially the employees that work in the evenings. The training session should including education on what questions to ask. What documentation to ask patients for and more. How to make photocopies. After the original training, supplemental online training course should be implemented. Employees will be required to complete online tutorials every 6 months. There also need to be proper documentation of employee compliance and errors. When these situations arise, they need to be addressed with the employee. It is also imperative that we look at or staffing specially though peak period at night. We need to have the correct amount of staffing in place so that nurses are not taking registration information. We need to let our...
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...Correct Medical Billing and Coding in the Healthcare Industry Medical billing and coding is one of today's topics. When services are billed for patients, they must be coded based on the documentation the physician has dictated in the patients chart to receive payment from the insurance company. As the physicians office and/or hospitals practice correct medical billing and coding, this will prevent audits being brought forth in their practice and/or hospital. Kenny, Christopher,Correct Coding for Dialysis Billing Providers must ensure proper coding to avoid returned claim, 2012. This article is geared for those in the medical field who do coding and billing in hospitals for dialysis. The author is educating the coders and billers how to correctly code for dialysis billing. He mentions that The Centers for Medicare and Medicaid, issued a transmittal that has revised the Medicare claims processing manual as it pertains to hospitals billing for dialysis procedures that are non covered under the ESRD benefit for emergency dialysis. In addition, the author discusses how the hospitals should utilize Healthcare Common Procedure Coding System billing code G0275 and code 90935 for hemodialysis. Only to bill G0275, if the hospital is a ESRD facility, emergency services, and when dialysis is performed with related procedures, such as a vascular access procedures or when performed following treatment for an unrelated medical emergency. The author also continues to...
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...Healthcare Compliance Assignment Week 4 Write a one page document covering the Case Study found on page 43 answering the following questions. Why is it important to use current codes and coding books? How could this error have been prevented? Would this claim have been denied? What are some of the effects of a denied claim? It's very important to use current codes and coding books. In this case study of Mrs. Cleett. If the Billing specialist hadn't checked the code before submitting the claim it could have been denied or delayed. Sometimes codes are revised and deleted. A new set of codes may tell you to code a different way. Using your coding books will keep you from over and under coding. It is also important to code from current coding books because the guidelines for a...
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