Evaluating Compliance Strategies
Andria Cogar
HCR/220
December 20, 2009
Summer Tierno
Evaluating Compliance Strategies
The medical billing and coding staff members working in physicians??™ offices have a very complicated and onerous job preparing bills to submit for payments of services rendered. They must make sure they are using the correct and updated Current Procedural Terminology, also known as CPT codes; but also be able to provide what procedures were done and why they were preformed as well. There are times when claims that are submitted were not complete and had to be denied until further detailed information could be provided.
There are several steps in the medical billing and coding process. In the medical billing process, after the patient encounters, physicians prepare and sign documentation of each patients visit. The next step is to post the medical codes and transactions of the patients visit in the practice management program to prepare the claims. The process used to generate claims must comply with the rules imposed by federal and state laws as well as with payer requirements. Coding specialists must be able to identify the bundling of codes; most offices go by Medicare??™s lists to ensure they are clear on the procedures provided (Valerius, 2008). CPT Modifiers must be used correctly so there is no confusion with the payer. This is where there can be implications of incorrect medical coding.
When procedures are performed, they must be consistent with the diagnosis to be sent in for payment. Payers provide offices with their own lists that they approve and provide the right ways to find codes allowed (Youngstrom, 2008). It is very important to link the diagnosis codes with the services that were provided because a patient was to receive a diagnosis of an allergic reaction to a medication but the procedure results in the patient being administered this medication, the patient could endure yet another allergic reaction. This could result in insurance company??™s paying for procedures that never occurred and denying procedures that really did take place.
Methods of evaluating compliance strategies in medical coding entail very little effort. Having meetings with the billing staff and doctors in order to make sure all updated code manuals have been distributed accordingly and making sure everyone involved knows how to use them appropriately. Most insurance companies have a trained employee attend these meeting to ensure proper use of the processes required. Seminars are also a great way to evaluate compliance strategies; this is to keep the billing staff up to date on any changes that have been made with the codes. The billing staff can go to the insurance company??™s different websites to look up information on the current codes that have been updated.
Health care provider??™s claims are always being audited in the process of compliance strategies. This is to see if the billing staff understands how to use the codes for claims. Auditors also want to ensure the billing process has been done correctly so there is no confusion of either party (Youngstrom, 2008). There are many errors in codes quit often, as well as duplicating billing and making sure bundled coding is done correctly. Auditors can be very beneficial for the billing staff because they help limit problems with errors if there is any found while doing the audit. Letting the billing staff know these audits are being done on a regular basis to ensure quality control keeps them on their toes; this can limit their mistakes because they want to ensure they are doing their job correctly; making sure to double-check their work.
I believe the process of evaluating compliance strategies works for the billing staff and the physicians. They try to do things by the book and are aware of when codes are changed or there is an update of codes because of insurance companies changes. Making sure that all persons involved in this field continues to go to meetings, seminars, and working with each other will ensure control over this field. Any job someone has gotten in the medical field can be very hard at times but, as long as questions are asked and manuals are by their sides I do not feel this is a problem and I agree with their methods. There are many different illnesses and diseases that are becoming new to every community and this is why codes have to be changed regularly.
References
Valerius, J., Bayes, N., Newby, C., & Seggern, J. (2008). Medical insurance: An integrated claims process approach (3rd ed.). Boston: McGraw-Hill.
Youngstrom, N. (2008). Medicare Compliance. AIS Education. Retrieved December 18, 2009, from http://www.aishealth.com/Compliance/ResearchTools/RMC_MD_Documentation.html
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