Evaluating Compliance Strategies
Evaluating Compliance Strategies
HCR/220
November 7, 2010
Evaluating Compliance Strategies This assignment will concentrate on medical billing, and compliance strategies, and the evaluation of these strategies. Many mistakes are made during the billing process, and some of the mistakes that are made could be caused by the strategies, and the processes themselves. In this essay I will offer a quick overview of the strategies, and an evaluation of these strategies. I will also offer my suggestions on how to fix the problems that were found in the evaluation. In this essay I will also attempt to answer these questions: What is the importance of correctly linking procedures and diagnoses? What are the implications of incorrect medical coding? How are medical coding, physician, and payer fees related to the compliance process? First among the strategies for compliance is defining bundled codes and knowing global periods. This step requires that the medical biller knows what procedures are involved in certain code bundles in order to keep from unbundling them. It suggests that the medical biller should become familiar with Medicare’s CCI list of bundling rules, as it is the most widely used set of rules on such procedures. It also says that if the payer has a unique set of codes, the medical biller must have access to such codes. This step works and has been used for years, but it is, and can be, very confusing. There are many different sets of codes that are used depending on who the payer is. Another problem that could result from this is that some of the code swapping could make it hard to link diagnoses with procedures. This is important because payers analyze this to see if charges are appropriate, or medically necessary. It is also important to do this because if a patient is diagnosed with a specific heart problem and then they receive anesthesia, this could cause a serious problem. Mixing codes from different payers could become a serious
HCR/220
November 7, 2010
Evaluating Compliance Strategies This assignment will concentrate on medical billing, and compliance strategies, and the evaluation of these strategies. Many mistakes are made during the billing process, and some of the mistakes that are made could be caused by the strategies, and the processes themselves. In this essay I will offer a quick overview of the strategies, and an evaluation of these strategies. I will also offer my suggestions on how to fix the problems that were found in the evaluation. In this essay I will also attempt to answer these questions: What is the importance of correctly linking procedures and diagnoses? What are the implications of incorrect medical coding? How are medical coding, physician, and payer fees related to the compliance process? First among the strategies for compliance is defining bundled codes and knowing global periods. This step requires that the medical biller knows what procedures are involved in certain code bundles in order to keep from unbundling them. It suggests that the medical biller should become familiar with Medicare’s CCI list of bundling rules, as it is the most widely used set of rules on such procedures. It also says that if the payer has a unique set of codes, the medical biller must have access to such codes. This step works and has been used for years, but it is, and can be, very confusing. There are many different sets of codes that are used depending on who the payer is. Another problem that could result from this is that some of the code swapping could make it hard to link diagnoses with procedures. This is important because payers analyze this to see if charges are appropriate, or medically necessary. It is also important to do this because if a patient is diagnosed with a specific heart problem and then they receive anesthesia, this could cause a serious problem. Mixing codes from different payers could become a serious
References: Fox, B. (2010). Implementing a compliance-based model of fraud risk control. Retrieved November 7, 2010 from EBSCOhost, University of Phoenix university library http://web.ebscohost.com.ezproxy.apollolibrary.com/ehost/pdfviewer/pdfviewer?vid=4&hid=107&sid=3f9e58a4-f20b-495f-8db7-bcf94e1efe9e%40sessionmgr112 Valerius, Bayes, Newby, Seggern (2008). Medical insurance: An Integrated Claims Process Approach, Third Edition. Retrieved November 7, 2010 from Axia College student materials web page https://ecampus.phoenix.edu/classroom/ic/classroom.aspx