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Office of Inspector General

By Pati Trites MPA CHBC, with Staff Reporters

Any readers considering enrolling in a medical coding school should read this ME-P.

Why? Because the written policies and procedures concerning proper health insurance and Medicare coding should reflect the current reimbursement principles set forth in applicable statutes, regulations and Federal, State or private payer health care program requirements, and should be developed in tandem with organizational standards.

Furthermore, written policies and procedures should ensure that coding and billing are based on medical record documentation; which is now the “reality” rather than just a “reflection” of the reality.

Focus on the Codes

Particular attention should be paid to issues of appropriate diagnosis codes, CPT, DRG and MS-DRG coding, individual Medicare Part A and B claims (including documentation guidelines for evaluation and management services) and the use of patient discharge codes. The billing company should also institute a policy that all rejected claims pertaining to diagnosis and procedure codes be reviewed by the coder or the coding department. This should facilitate a reduction in similar errors.

Problem Areas

Among the risk areas that some billing companies who provide coding services should address are:

• Internal coding practices;
• “Assumption” coding;
• Upcoding and Downcoding;
• Alteration of medical records and documentation;
• Coding without proper documentation of all physician and other professional services;
• Billing for services provided by unqualified or unlicensed clinical personnel;
• Availability of all necessary documentation at the time of coding; and
• Employment of sanctioned individuals.

Assessment

Billing companies that provide coding services should maintain an up-to-date user-friendly index for coding policies and procedures to ensure that specific information can be readily located.

Similarly, for billing companies which provide coding services, the physician-executive and billing company should assure that essential coding materials are readily accessible to all coding staff.

Finally, billing companies should emphasize in their standards the importance of safeguarding the confidentiality of medical, financial and other personal information in their possession.

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Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

• PRACTICES: www.BusinessofMedicalPractice.com
• HOSPITALS: http://www.crcpress.com/product/isbn/9781466558731
• CLINICS: http://www.crcpress.com/product/isbn/9781439879900
• ADVISORS: www.CertifiedMedicalPlanner.org
• FINANCE: Financial Planning for Physicians and Advisors
• INSURANCE: Risk Management and Insurance Strategies for Physicians and Advisors
• Dictionary of Health Economics and Finance
• Dictionary of Health Information Technology and Security
• Dictionary of Health Insurance and Managed Care

Filed under: Accounting, Health Insurance, Health Law & Policy, Practice Management |