Five Cardinal Compliance Rules

Posted on February 7, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Proper Use / Billing of CPT® and Diagnosis Codes

The health care industry operates in a heavily regulated environment with a variety of identifiable risk areas. An effective compliance program helps mitigate these risks.

-Corporate Responsibility and Corporate Compliance  [A Resource for Health Care Boards of Directors] 

The Five Cardinal Compliance Rules to Follow

 By Patricia A. Trites; PhD, MPA, CBC, CMP™ [Hon]

After completing and documenting a medical service, the next step is to “code” the procedure and the diagnosis for payment.

The Rationale

CPT® codes are updated annually and each healthcare organization should be sure to use current codes.

And, it is also important to make sure that these codes are not contingent upon whether payment will be made for the service, but should reflect the service(s) and the reason for the service(s) provided. 

Much has been written on selecting the correct procedure codes and the associated documentation that is required for each level of service. There are also rules associated with selecting the correct diagnosis code. The key issue in determining if a provider can be paid for their services is to show that there was a medically justifiable reason for performing the procedure or service.

Justifiability Requirements

Justifiability is established primarily by looking at the CPT® or procedure code that was billed in relation to the ICD-9 or diagnosis code that was given as the reason for the encounter or procedure. If medical necessity can be shown, the likelihood is that the bill will be paid.

The Cardinal Rules 

The basic requirement is that the diagnosis must justify the procedure.  If the following five rules are followed, there is a much better chance that the claim(s) will be paid.

 

  1. Code all diagnoses to the ultimate specificity
  2. Use additional code(s) and code any underlying diseases when necessary
  3. Code all the conditions encountered during the service to fully describe the encounter
  4. Choose the appropriate principal diagnosis and sequence all secondary codes correctly
  5. Avoid using .8 And .9 “catch-all” codes.

Conclusion 

As a provider or medical executive – do you code yourself or use an ancillary coder; in-house or out-sourced and why?  Please opine and comment. 

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The Medical Malpractice Discovery Process

Posted on February 7, 2008 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding the Legal System

 By Dr. Jay S. Grife; JD, MAinsurance-book

Since most medical negligence cases are fact driven, the topic of discovery demands a specific and integral role in the trial process.  Discovery simply is the methodology used in American jurisprudence for each side to discover all of the evidence that is available in the case and to have that documentation analyzed. While specific states have rules that may limit discovery, the purpose is to prevent trial by ambush.  

Federal Rules of Civil Procedure 

According to the Federal Rules of Civil Procedure [FRCP], discovery can include written interrogatories or questions, requests for production, deposition, either oral or through written statements, request for examination, request for inspection of evidence, requests for admission, and finally independent, or as Plaintiffs’ lawyers commonly label them, compulsory medical examinations. 

Definition and Scope 

The scope discovery methods are generally a book onto itself. So, suffice it to say, discovery is the process where each party exchanges information so the merit of their respective cases can be evaluated.  Lawyers will use this evidence in developing the theory of their case and the order in which that evidence will be presented to the trier of fact.

Conclusion 

While discovery is often viewed as a mundane part of the litigation process, in reality it is the very topic that often proves dispositive in the ultimate outcome of a medical malpractice case; whether it is tried, settled, or rejected.

And so, your comments are appreciated? 

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