Evaluating Compliance Strategies
Evaluating Compliance Strategies
HCR/220
January 3, 2011
Fonzette Mixon
Evaluating Compliance Strategies
The compliance process is set up to ensure the maximum appropriate reimbursement for health care claims. Correct billing and coding are directly linked to correct documentation by a physician. Also, to complete documentation, linking the correct code to the correct diagnoses is a must. This step is vitally important in reducing compliance errors. Second, the implications of incorrect coding can have a domino effect and will ultimately cause many people in the chain of events to go back, review, correct the errors, and resubmit the claim. This could also cause the patient and payer more money or cause a claim to be denied. Additionally, medical coding, physician, and payer fees are connected because they affect how much a payer will cover, a patient will pay, and how much a practice will charge for services. Physician and payer fees are both built on different systems that allow for the determination of the cost for procedures and services. In the end, this will determine what a patient will have to pay. A combination of correct and thorough documentation by the physician, correct coding, and complete compliance with billing regulations will ultimately reduce errors and ensure that providers, payers, and patients will be billed and reimbursed properly.
The Medicare National Correct Coding Initiative (CCI) is designed to control improper coding and avoid inappropriate payment for Medicare claims. CCI updates the system quarterly and uses thousands of CPT code combinations, called CCI edits, to check all claims for potential coding or billing errors. CCI edits apply to claims that bill for more than one procedure on the same day and by the same provider. CCI edits work with all Medicare computers to scan for claims that do not pass an edit and will therefore be denied. Such situations, like double billing, might happen if a claim is processed
HCR/220
January 3, 2011
Fonzette Mixon
Evaluating Compliance Strategies
The compliance process is set up to ensure the maximum appropriate reimbursement for health care claims. Correct billing and coding are directly linked to correct documentation by a physician. Also, to complete documentation, linking the correct code to the correct diagnoses is a must. This step is vitally important in reducing compliance errors. Second, the implications of incorrect coding can have a domino effect and will ultimately cause many people in the chain of events to go back, review, correct the errors, and resubmit the claim. This could also cause the patient and payer more money or cause a claim to be denied. Additionally, medical coding, physician, and payer fees are connected because they affect how much a payer will cover, a patient will pay, and how much a practice will charge for services. Physician and payer fees are both built on different systems that allow for the determination of the cost for procedures and services. In the end, this will determine what a patient will have to pay. A combination of correct and thorough documentation by the physician, correct coding, and complete compliance with billing regulations will ultimately reduce errors and ensure that providers, payers, and patients will be billed and reimbursed properly.
The Medicare National Correct Coding Initiative (CCI) is designed to control improper coding and avoid inappropriate payment for Medicare claims. CCI updates the system quarterly and uses thousands of CPT code combinations, called CCI edits, to check all claims for potential coding or billing errors. CCI edits apply to claims that bill for more than one procedure on the same day and by the same provider. CCI edits work with all Medicare computers to scan for claims that do not pass an edit and will therefore be denied. Such situations, like double billing, might happen if a claim is processed
References: Micheletti, J.A. (2005). Improving physician documentation enhances compliance. Journal of Healthcare Compliance, 7(5), 53-58. Retrieved from http://proquest.umi.com.ezproxy.apollolibrary.com/pqdweb?did=897561081&sid=2&Fmt=4&clientId=13118&RQT=309&VName=PQD Valerius, J., Bayes, N. L., Newby, C. & Seggern, J.I.B. (2008). Medical insurance: an integrated claims process approach (3rd ed.). New York, NY: McGraw-Hill.