Chapter 7 Visit Charges & Compliant Billing

Chapter 7
Visit Charges & Compliant Billing
OT 232
OT 232 Ch 7 lecture 1
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
Knowledge of Billing Rules
• Must keep up-t0-date!
– Insurance companies have bulletins, websites, etc.
• Easier in a specialized office because less to
OT 232 Ch 7 lecture 1
Medicare Regulations:
The Correct Coding Initiative
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
OT 232 Ch 7 lecture 1
CCI (cont’d.)
• Also tests for unbundling
– Incorrect billing practice of breaking a package of
services into component parts & reporting them
• Requires physicians to report only the more
extensive version of the procedure performed
OT 232 Ch 7 lecture 1
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
Organization of CCI edits (cont’d.)
• Mutually Exclusive Code Edits
– Also uses 2 columns
– Cannot be billed together
– Medicare pays lower-paid
– Ex pg 210
OT 232 Ch 7 lecture 1
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
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
– Hysterectomy on a male
• Will also reject billings in excess of Medicare
OT 232 Ch 7 lecture 1
Other Government Billing
• The OIG Work Plan
– Issued annually as part of Medicare Fraud and Abuse
– 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
– 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
OT 232 Ch 7 lecture 1
– Knowingly hiring excluded companies/people is illegal
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
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
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
• Criteria varies by payer
– The procedures are furnished at an appropriate
OT 232 Ch 7 lecture 2
Errors relating to the Coding
• Truncated coding
– Billing tip, pg 213
• Gender/age mismatch
• Assumption coding, altering documentation after
services are reported, coding w/out proper
• Reporting services provided by unlicensed or
unqualified personnel
• Not satisfying the conditions of coverage of a
particular service
OT 232 Ch 7 lecture 2
Errors related to the Billing
• Billing noncovered services
– If in doubt, look it up in the Schedule of Benefits
Billing a consultation instead of an office visit
Billing outdated codes
‘Upcoding’ or ‘downcoding’
Billing without signatures
OT 232 Ch 7 lecture 2
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

similar documents