Evaluating Compliance Strategies

The compliance process is very important in medical billing and coding. After a patient is seen, physicians document the patient 's visit. Medical administrators then post the medical codes of the visit in the practice management program (PMP) and prepare the claim. It is important to prepare claims correctly in order to stay in compliance. A correct claim connects a billed service to a diagnosis. The diagnosis has to relate to the billed service to treat the patient 's ailment. The connection is referred to as code linkage. It is important to correctly link procedures and diagnosis ' because if they aren 't correctly link the payer will reject the claim and will not pay for the services which then makes the patient responsible for payment. To be in compliance, medical insurance specialists need to know each payer 's billing rules stated in each insurance policy. These are subject to change and updated frequently so medical insurance specialists also use payer bulletins, websites, and maintain communication with payer representatives to make sure they are staying in compliance. Medicare also has its own set of rules and regulations. The Medicare National correct coding initiative (CCI) controls improper coding. CCI edits are used by computers to check claims for errors that would lead to improper payment of services. The CCI prevents two procedures from being billed that could not have been performed together. Private payers also have code edits similar to the CCI. Compliance errors sometimes occur. Submitting an improper claim may just be a simple mistake such as a typo, or sometimes it may be a deliberate act of fraud. Other common errors that are sometimes made are truncated coding, incorrect gender or age of the patient, assumption coding, altering documentation, coding without proper documentation, reporting services provided by unlicensed providers, and coding a unilateral service twice instead of choosing the bilateral code. For these reasons there are

References: http://www.cleveland.com/healthfit/index.ssf/2012/06/medical_billing_errors_what_ca.html