Saturday, July 18, 2009

Robotics in the operative field

Use of Robotics in the operative field... Coding/billing options

As you may know the use of the operative robotic assist in the OR is really booming at this time... Right now, Urologists are using robotics for prostatectomies, OB/Gyns are using them for hysterectomies and other abdominal surgery, and Orthopedics is using them for Total Hips/Knee replacements....

As a coder, there are not any CPT codes that currently encompass use of a robotic device in surgery. So that leaves few options for billing the procedures.

First of all, before your physician performs the surgery, phone the insurance carrier to see if they will pay for a procedure that utilizes a robotic device. Some carriers regard this as "experimental" and will not pre-authorize or pay based upon that.

If you are lucky and the carrier does allow robotics.. your options for billing cpt codes are limited to only 2 options...

Option A: code the surgery with the CPT code that most closely resembles the surgery without the use of the robotic device, and add modifier 22 to show that your physician performed the procedure but with increased services

Option B: code the surgery as an "unlisted" code and note in the remarks line that this surgery most closely resembles code XXXXX but was performed with the assist of robotics.

With either option, be sure to send the carrier a copy of the operative note, and price your surgery competitively with your other surgeries.

Follow up with your carriers to ensure that they have recieved your claim, and will process in a timely manner.

Last but not least... keep your patient informed, and you may want to insist that your patient sign an advanced information document similar to an ABN, and collect for the surgery cost up front, or have a payment plan with the patient put on file.

However, I do recommend that you always perform your "due diligence" with any surgical procedure that is scheduled in advance:

** pre-authorize with the insurance carriers ANY surgery, (or surgical procedure)

** inform your patient up-front of the pre-auth findings

** Have an ABN signed (or ABN type document) by the patient clearly outlining what the cost for the surgical procedure is, and how much they (as the patient) could potentially be responsible for.

** Have a billing consent, a surgical consent, and a HIPPA & Privacy statement signed by your patient and on-file in your chart.

** Schedule the surgery!!!

Happy Coding & Billing....

Luvs.... L : )

Words of Wisdom from Maya Angelou...

I rec'd this from my "Sister Bobbi" .. Great words of wisdom from Maya Angelou...

In April, Maya Angelou was interviewed by Oprah on her 70 birthday. Oprah asked her what she thought of growing older.

And, there on television, she said it was 'exciting.' Regarding body changes, she said there were many, occurring every her breasts. They seem to be in a race to see which will reach her waist, first.

The audience laughed so hard they cried. She is such an honest woman, with so much wisdom in her words!

Maya Angelou said this:

"I've learned that no matter what happens, or how bad it seems today, life does go on, and it will be better tomorrow.

"I've learned that you can tell a lot about a person by the way he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree lights.?

"I've learned that regardless of your relationship with your parents, you'll miss them when they're gone from your life.

"I've learned that making a 'living' is not the same thing as 'making a life.'

"I've learned that life sometimes gives you a second chance.

"I've learned that you shouldn't go through life with a catcher's mitt on both hands; you need to be able to throw some things back.

"I've learned that whenever I decide something with an open heart, I usually make the right decision.

"I've learned that even when I have pains, I don't have to be one.

"I've learned that every day you should reach out and touch someone. People love a warm hug, or just a friendly pat on the back.

"I've learned that I still have a lot to learn.

"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

Pass it on!

Thursday, July 16, 2009

Physician coding for Dental Surg Clearance

Hi -- I rec'd this Q the other day and thought I'd post for you...

Coding a “medical clearance for dental surgery”

Q: How would you code an h&p (history and physical) when the patient is going to go under for dental work? The doctor only did the h&p and I thought it would be coded to 99212, 99213. What do you say? Thanks a bunch . . .

A: If the physician is doing the medical clearance for dental surgery, he can do the 99212,99213 (or appropriate level of E&M) OR he can bill a consultation or New patient code. The driver for this scenario, is that the physician will need to report any "diagnosis" that might affect how surgery goes, AND include the dx of V72.83 which encompasses the pre-procedure general physical exam.

(FYI, these may or may not be payable from the insurance carrier, so you might want to have an ABN on file for this, and collect up front!. Thx... L

Monday, July 13, 2009

Chapter 6: Emerging issues and challenges

** RAC Audits – The big challenge for any coding manager!
** OIG Workplan 2010
** ICD-10
** Coding Ethics
** Negotiating Contracts

RAC – What does it mean? We hear many acronyms within the coding and billing industry, so it is wise to find out what they mean, and how they impact us. RAC is the Recovery Audit Contractor program set up by CMS( Centers for Medicare/Medicaid services) . Their mission is to reduce Medicare’s improper payments through efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments.(

The RAC program was developed and implemented in March of 2005, and had been charged with 2 objectives, 1) to detect improper payments billed by providers of Medicare services and 2) to correct improper payments made by Medicare to providers of Medicare services. The RAC program was initiated as a demonstration project. CMS hired independent contractors to evaluate billing and payment information from 3 states, California, Florida, and New York. These contractors were provided with claim information beginning October 1, 2001 through 2005. The contracted RAC auditors receive a percentage of all payments recouped by them.
Medicare will continue doing pre-payment claims review utilizing the National Correct Coding Initiatives (NCCI) edts, and the Medically Unlikely Edits (MUE) In addition, they will also continue the CERT program The NCCI, edits , MUE, CERT reviews and now the RAC are the current tools being used by CMS to review claims by providers.

In addition to CMS, the OIG (Office of Inspector General) and the GAO (General Accounting Office) to target improper payments. When the numbers were initially compiled and released, in 2006, CMS stated that approximately 54 million dollars were returned to the CMS Medicare system for the 3 states identified in the demonstration project.

Where did the RAC’s find all these dollars? According to CMS, the majority of the dollars recouped came from inpatient hospitals, and hospital based facilities. CMS figured of the 54 million, it breaks down as 84% Inpatient hospital, 14% Outpatient hospital, 1% DME (Durable Medical Equipment, and the last 1% to Physician, Ambulance, Lab and Ancillary services. Out of those percentages, they found that 40% of these claims were for services deemed (by CMS ) as medically unnecessary, 30% percent as incorrectly coded, then had 25% that either had no documentation, insufficient documentation, or other miscellaneous reasons. With analysis of these findings, it really raises the scrutiny upon the coding department. The coding manager needs to respond, and to encourage and educate their coders and physicians to correctly document, code and bill these claims. This also should set the wheels in motion, to get your physicians and hospital based staff documenting clearly, concisely efficiently and straightforwardly.

In 2007, the RAC expanded the program to include the states of Massachusetts, South Carolina and Arizona. The success of dollars recouped from the RAC demonstration project, convinced congress to mandate the RAC program as a permanent part of the CMS system. By January 1, 2010 this program will be expanded to all 50 states and the 4 regions will be rolled out for audit scrutiny on a state by state basis, then by a designated claim type basis.

With the RAC going nationwide in 2010, CMS has changed some of the criteria requirements of the study. These changes were implemented. Concern was voiced by providers, hospital associations and some senators on Capitol Hill regarding the scope of work from the RAC. Some of the critical changes that the RAC has incorporated into the permanent RAC program is listed below. This is not an all encompassing list, but a few of the attention critical areas affected.:

 The program can only look back at 3 years of data, and cannot look back any further than October 1, 2007.

 Certified coding experts are mandatory under the permanent program
 The RAC must have a medical director in the permanent program
 The credentials of the reviewers must be provided and disclosed under the permanent program
 An external validation process will now be mandatory to ensure that the payment was truly an overpayment, and not just human error, or an inadvertent billing issue.

Tentatively the rollout process will happen in phases.. See figure 6-1 2010,
The RAC have a finalized specific SCOPE OF WORK (SOW) that they will adhere to. The RAC’s MAY NOT review services provided under a program other than the Medicare Fee for Service Program (MFS) , The RAC program cannot review medicare entitlement programs such as the Medicare Advantage Plan, True Blue, Health Sense 65 etc that are independent of the MFS program. In addition, the RAC cannot review claims where the beneficiary is liable for the overpayment. Such as if the patient has a signed an ABN on file, or requested services that are statutorily excluded from the Medicare (MFS) program. RAC’s cannot review claims dated earlier than October 1, 2007, or claims more than 3 years post claim paid date. Interestingly, they cannot review a claim that went in for a prepayment review process.

The RAC’s will be able to review claims via automated review processes. These processes will happen within a software database scrubbing system to look for excessive units billed, or incorrect discharge status codes. The automated reviews will not need to have the medical record for the audit process. The system will also review duplicate claims and multiple claims for the same patient on the same day for the same services.

The complex review process utilizes the medical record to evaluate whether or not payment should have been made. Also within the RAC Scope of Work, RAC’s may review incorrect payment amounts, non-covered services, and incorrectly coded services. MSDRG mis-coding will be a focus for the RAC’s. In addition, RAC’s will also look at duplicate services provided.

If all goes according to the outlined plan, by 2010, CMS will have the 4 permanent RAC’s in place. Each RAC will be responsible for identifying overpayment and underpayments in approximately ¼ of the country. The new RAC jurisdictions will match the current DME/MAC jurisdictions.
On October 6, 2008, CMS announced the names of the new national RACs. The new RACs are listed below. During 2009, the additional states will be added to each RAC region as listed below..

• REGION A: Diversified Collection Services, Inc. of Livermore, California, currently working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York.

• REGION B: CGI Technologies and Solutions, Inc. of Fairfax, Virginia, currently working in Michigan, Indiana and Minnesota.

• REGION C: Connolly Consulting Associates, Inc. of Wilton, Connecticut, currently working in South Carolina, Florida, Colorado and New Mexico.

• REGION D: HealthDataInsights, Inc. of Las Vegas, Nevada, currently working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona.

The RAC’s also have specific target areas that hospital coding managers should pay specific attention to. These identified coding targets are
 Code 86.22 reporting of excisional debridement. They want to make sure there is clear documentation in the medicare record to meet medical necessity, and that the “excisional” area has also been clearly noted.

 DRGs designated as CC or MCC with only one secondary diagnosis. Such as
o MSDRG 329 Major Small & Large bowel with MCC
o MSDRG 330 Major Small & Large bowel with CC
o MSDRG 331 Major Small & Large bowel w/o cc/MCC

 Correct coding of discharge status for post acute care transfer (discharge status codes) For the correct coding of discharge status the RAC’s will look at the entire history of a patients’ claims.. i.e. if the hospital codes the claim as a discharge home, but the patient goes to another hospital, the claim will be identified and denied. The hospital will then need to re-bill the discharge correctly

 Wrong Principal Diagnosis – In the demonstration project, the principal diagnosis reported on the claim did not mach the principle diagnosis recorded in the medical record.

 Incorrect Coding – such as (but not all inclusive) the reported principle diagnosis was septicemia, but the medical record only showed a diagnosis of urosepsis, and the blood cultures were negative for septicemia.

 Unit coding errors were also a big factor in the demonstration project, CMS identified this listing as the top unit coding error types (

o grams vs. milligram,
o number or procedures per day (e.g., appendectomy, colonoscopy) (automated review)
o blood transfusion 36430, billed 1 service per pint rather than 1 service per transfusion session (automated review)
o speech/hearing therapy 92507, billed 1 service per 15 minutes rather than 1 service per session. Processing manual 100-5, Chap 5, Sec 20.2 (automated review)
o HCPCS code J2505, billed 1 service per mg when the definition of the code is 1 service per 6 mg vial. Transmittal 949. (automated review)

As the coding manager, you will need to establish a good process for dealing with RAC requests. This should be a similar process to what you have in place for current CMS audit requests. You should assemble a inter-facility RAC team. This team should include and utilize other departments expertise such as the Compliance, Accounting, Patient Fianancial Services, Utilization Review, Risk Management, Legal, Physician/Medical Staff departments, and of course... your HIM/Coding department. Some facilities may even want to include an outside entity such as a Physician Medical Association, or Hospital association(s) they are affiliated with to participate on your RAC identification and review team.

Next up, you should establish a process protocol for dealing with a RAC review. The goals of this team should be to review each and every RAC review request. This team should meet (at minimum) once per month. In addition to reviewing the request, the team should also review all replies, records, and documentation being sent back to the RAC for each specific request. If needed, you can contact the RAC and request additional time to comply with their request for forwarding the information to them. However, they do not have to grant your request.

Make sure that you and your team have implemented a good tracking system for these requests. Document and copy each request/demand letter, be sure to separate the requests by review type; automated review, or complex review. In addition to the review type, look at each review request by type of issue such as, duplicate payments, medical necessity, and DRG errors. If the RAC letters are confusing, or; you do not understand what the RAC is requesting, contact the RAC liaison who is listed on the letter for more clarification. Document the date and time if you quested this information if you contacted the RAC via phone, fax or in person. However, I would suggest making this request to the RAC liaison as a formal request from your in-house RAC team and file with the rest of your RAC log protocols.

CMS has outlined the RAC review process and Medicare appeal process as noted in the figure above. In the next figure 6-4, you will note that CMS has informed you that if you begin the appeal process within 30 days they will not automatically begin the recoupment process. This is huge for your RAC review team to look at and abide by.

So as a coding manager, you need to begin working immediately to get a good RAC process team in place and really scrutinize and audit your medical records and coding processes. Again, it is always better to do it right the first time through, than to correct your errors on the back end. No one wants to be a RAC target, but again, if you are subject to a RAC audit and your documentation and records bear out without errors, then you should celebrate your successes. Continue reviewing and making needed corrections in your policies and protocols PRIOR to having the error discovered by an outside entity.

OIG Workplan:

The mission of the OIG is to conduct and supervise audits and investigations relating to the programs and operations of CMS and HHS. They also provide leadership and recommend policy for CMS and HHS. They also protect the integrity of these programs, such as Medicare and Medicaid by detecting (and hopefully preventing) fraud and abuse by providers and suppliers.
Annually, the OIG will review and identify areas of issue that may require more attention within the coming work year. This list is not a static listing, but due to the changing nature of the medical arena, they will shift focus as needed so that they can keep congress abreast of issues and trends that are happening within the medial field.
The listing below shows the areas the OIG intends to focus on in the FY 2009. As a coding manager, you will want to review the OIG’s workplan every year, to identify and correct any potential problem areas within your practice or facility. Place of service errors has really come under fire recently, due to the POA requirements for hospitals. In the office/outpatient areas, modifier “GY” is being scrutinized for improper usage, so you may want to clarify what and why the modifier is necessary on your claims. The other critical focus for the office/outpatient area is the “incident to” rules for non-physician practitioners. “Incident to” has always been a very difficult area to comply with, as the rules for incident to are not very clearly outlined by CMS. Therefore, I think any time you are using “incident to” for claims billing, this is a potential area for error and abuse. The list below is direct from the OIG. It is not an all-inclusive list, you can view the entire listing on this website, However, the listing of targeted work areas below will be vital as a coding manager to review, and include in the audit and education processes for your departments. The monitoring of the yearly OIG work plans should be an integral part of your coding management duties. Outlined below are some of the areas of interest for those managers who are in the hospital arena, and those in the office/outpatient setting.

 Part A Hospital Capital Payments
o The OIG will review Medicare inpatient capital payments. Capital payments reimburse a hospital’s expenditures for assets, such as equipment and facilities. The basic methodology for determining capital prospective rates is found at 42 CFR § 412.308. We will determine whether capital payments to hospitals are appropriate. We will examine the methodology used to update capital rates and analyze the appropriateness of the payment level. (OAS; W-00-08-35300; various reviews; expected issue date: FY 2009; work in progress)
 Additional Part A Medicare Capital Payments for Extraordinary Circumstances
o The OIG will review additional Medicare capital payments made to hospitals for extraordinary circumstances. Pursuant to Federal regulations at 42 CFR § 412.348(f)(1), hospitals may request additional Medicare capital payments if they incur unanticipated capital expenditures in excess of $5 million (net of proceeds from other payment sources, such as insurance; litigation decisions; and other local, State, or Federal government funding programs) owing to extraordinary circumstances beyond their control (e.g., a flood, a fire, or an earthquake). We will determine whether the additional Medicare capital payments made to hospitals for extraordinary circumstances were in accordance with Federal requirements. (OAS; W-00-09-35216; various reviews; expected issue date: FY 2009; new start)

 Provider-Based Status for Inpatient and Outpatient Facilities
o The OIG will review cost reports of hospitals claiming provider-based status for inpatient and outpatient facilities. Since the beginning of the Medicare program, some hospitals have operated as single entities while owning and operating multiple provider-based departments, locations, and facilities that were treated as part of the main hospital for Medicare purposes. Pursuant to 42 CFR § 413.65(d), CMS has the authority to grant provider-based status for facilities that are separate from the hospital, both on and off campus, that meet specific requirements. Hospitals with provider-based facilities may receive higher reimbursement when they include the costs of a provider-based entity on their cost reports. Freestanding facilities may also benefit from enhanced disproportionate share hospital (DSH) payments, upper payment limit (UPL) payments, or graduate medical education payments for which they would not normally be eligible. In addition, provider-based status for outpatient clinics may increase coinsurance liability for Medicare beneficiaries. We will determine the potential impact on both the Medicare program and its beneficiaries of hospitals improperly claiming provider-based status for inpatient and outpatient facilities. (OAS; W-00-08-35424; various reviews; expected issue date: FY 2009; work in progress)

 Part A Inpatient Prospective Payment System Wage
o The OIG will review hospital and Medicare controls over the accuracy of the hospital wage data used to calculate wage indices for the IPPS. Hospitals must accurately report wage data for CMS to properly calculate the wage index in accordance with the Social Security Act, § 1886(d)(3). Our prior work found hundreds of millions of dollars in misreported wage data. We will determine whether hospitals have complied with Medicare requirements for reporting wage data and determine the effect on the Medicare program of incorrect diagnosis-related group (DRG) reimbursement caused by inaccurate wage data. We will also examine the appropriateness of using hospital wage indices for other provider types. (OAS; W-00-07-35142; W-00-08-35142; various reviews; expected issue date: FY 2009; work in progress)

 Inpatient Hospital Payments for New Technologies
o The OIG will review payments made to hospitals for new services and technologies. Pursuant to the Social Security Act, §§ 1886(d)(5)(K) and (L), Medicare’s new technology payments consist of payments for new medical services and technologies that qualify as new under 42 CFR § 412.87 and are demonstrated to be otherwise inadequately paid under the DRG system. We will determine whether hospitals have submitted claims in accordance with the criteria. We will also review CMS’s calculation of the payments. (OAS; W-00-09-35191; various reviews; expected issue date: FY 2010; new start)

 Critical Access Hospitals
o The OIG will review payments made to critical access hospitals (CAH). Pursuant to the Social Security Act, §§ 1814(l)(1) and 1834(g), CAHs are generally paid 101 percent of the reasonable costs of providing covered CAH services. We will determine whether CAHs have met the CAH designation criteria set forth in the Social Security Act, § 1820(c)(2)(B) and conditions of participation set forth at 42 CFR pt. 485, subpart F, and whether payments made to CAHs were made in accordance with Medicare requirements. (OAS; W-00-07-35101; W-00-08-35101; various reviews; expected issue date: FY 2009; work in progress)

 Reliability of Hospital-Reported Quality Measure Data
o The OIG will review hospitals’ controls for ensuring the accuracy of data related to quality of care that they submit to CMS for Medicare reimbursement. The Social Security Act, § 1886(b)(3)(B)(vii), requires that hospitals report quality measures for a set of 10 indicators established by the Secretary as of November 1, 2003. Section 501(b) of the MMA established a reduction in payments of 0.4 percent to hospitals that did not report quality measures to CMS. The Social Security Act, § 1886(b)(3)(viii), as added by section 5001(a) of the DRA, expanded this payment reduction to 2 percent effective at the beginning of FY 2007. We will determine whether hospitals have implemented sufficient controls to ensure that their quality measurement data are valid. (OAS; W-00-09-35218; various reviews; expected issue date: FY 2010; new start)

 Payments for Diagnostic X Rays in Hospital Emergency Deparatments
o The OIG will review a sample of Medicare Part B paid claims and medical records for diagnostic x-rays performed in hospital emergency departments to determine the appropriateness of payments. Radiology services furnished by a physician are reimbursed by the MPFS provided that the conditions for payment for radiology services at 42 CFR §§ 415.102 (a) and 415.120 are met. The Medicare Payment Advisory Commission (MedPAC), in its March 2005 testimony before Congress, reported concerns regarding the increasing cost of imaging services for Medicare beneficiaries and potential overuse of diagnostic imaging services. In 2004, about 4.7 million diagnostic x rays were performed in Medicare-certified hospitals with emergency departments, a 9.6-percent increase since 2001. Medicare spent approximately $48.3 million for these services in 2004. We will determine the appropriateness of payments for diagnostic x rays and interpretations. (OEI; 00-00-00000; expected issue date: FY 2010; new start)

 Oversight of Hospitals’ Compliance With the Emergency Medical Treatment and Labor Act (EMTALA)
o The OIG will review CMS’s oversight of hospitals’ compliance with the Emergency Medical Treatment and Labor Act of 1986 (EMTALA). Pursuant to the Social Security Act, §§ 1866 and 1867, and regulations at 42 CFR § 489.24, hospitals must agree to comply with EMTALA requirements. Hospitals with emergency departments are required to provide medical screening examinations to individuals who come to their emergency departments requesting such examinations, regardless of whether the individuals have insurance. CMS is responsible for evaluating EMTALA complaints and referring to State licensing agencies cases that warrant investigation. CMS may terminate facilities’ participation in Medicare if investigations, which must include peer review if a medical opinion is required, identify EMTALA violations. A previous OIG review raised concerns about CMS’s EMTALA oversight, specifically regarding long delays to investigate complaints and inadequate feedback provided to hospitals on alleged violations. We will identify any variation among regions in the number of EMTALA complaints and cases referred to States, examine CMS’s methods for tracking complaints and cases, and determine whether required peer reviews have been conducted prior to CMS’s making a determination about whether to terminate noncompliant providers from the Medicare program. (OEI; 00-00-00000; expected issue date: FY 2009; new start)

 Coding and Documentation Changes Under the Medicare Severity Diagnosis Related Group System
o The OIG will review the impact of the October 1, 2007, implementation of the Medicare Severity Diagnosis Related Group (MS-DRG) system. CMS revised its hospital inpatient reimbursement system to improve recognition of severity of illness and resource consumption, as recommended in a March 2005 MedPAC report. As a result, the number of DRGs has increased from 538 to 745. We will examine coding trends and patterns under the new system and determine whether specific MS-DRGs are vulnerable to potential upcoding. (OEI; 00-00-00000; expected issue date: FY 2010; new start)

 Serious Medical Errors (“Never Events”)

o The OIG will review the incidences of and payments for serious medical errors, known as “never events,” in the Medicare population. Section 203 of Division B of the Tax Relief and Health Care Act of 2006 (TRHCA) requires OIG to conduct a study of never events, examining types of events and payments by any party; the extent to which the Medicare program paid, denied payment, or recouped payment for services furnished in connection with such events; and the extent to which beneficiaries paid for such services. OIG is also required to review CMS’s administrative processes regarding detecting and paying for never events. We will conduct a series of reviews to address the requirements of this mandate. More specifically, we will review key issues, policies, and practices regarding never events in hospitals. We will also conduct a review of hospitals’ compliance with CMS requirements by identifying several hospital-acquired conditions using the Present on Admission coding system implemented on October 1, 2007. (OAS; W-00-08-35422; various reviews; expected issue date: FY 2009; work in progress; OEI; 06-07-00470; 06-07-00471; 06-08-00220; various reviews; expected issue dates: FY 2009 and 2010; work in progress and new start)


 Billing services “incident to” when the non-physician practitioner was not qualified to perform the services

o The OIG will review services physicians bill to Medicare but do not perform personally. Such services, called “incident to,” are typically performed by non-physician staff members in physicians’ offices. The Social Security Act, § 18610(s)(2)(A), provides for Medicare coverage of services and supplies performed “incident to” the professional services of a physician. However, these services may be vulnerable to overutilization or put beneficiaries at risk of receiving services that do not meet professionally recognized standards of care. We will examine the qualifications of nonphysician staff that perform “incident to” services and assess whether these qualifications are consistent with professionally recognized standards of care. (OEI; 09-06-00430; expected issue date: FY 2009; work in progress)

 Improper billing of evaluation and management services during global surgery periods
o The OIG will review industry practices related to the number of evaluation and management (E&M) services provided by physicians and reimbursed as part of the global surgery fee. CMS’s “Medicare Claims Processing Manual,” Pub. No. 100-04, ch. 12, § 40, contains the criteria for the global surgery policy. Under the global surgery fee concept, physicians bill a single fee for all of their services usually associated with a surgical procedure and related E&M services provided during the global surgery period. We will determine whether industry practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992. (OAS; W-00-07-35207; various reviews; expected issue date: FY 2009 and FY 2010; work in progress)

 Billing for services using unlisted procedure codes
o The OIG will review the accuracy of Medicare payments for services billed using unlisted procedure codes. Unlisted procedure medical codes are miscellaneous codes used by service providers only when there are no specific Healthcare Common Procedure Coding System (HCPCS) codes that accurately identify the medical service furnished. The Social Security Act, § 1848(a)(1), establishes the MPFS, which provides a payment amount for almost all HCPCS codes, as the basis for Medicare reimbursement for physician services. However, unlisted procedure codes are not paid under the fee schedule. The Medicare contractors that process such claims suspend them for individual review and manual pricing. We will examine provider usage of procedure codes for services not listed in the HCPCS. (OEI; 00-00-00000; expected issue date: FY 2010; new start)

 Improper use of modifier GY
o The OIG review the appropriateness of providers’ use of modifier GY on claims for services that are not covered by Medicare. CMS’s “Medicare Carriers Manual,” Pub. No. 14-3, pt. 3, § 4508.1, states that modifier GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service. Beneficiaries are liable, either personally or through other insurance, for all charges associated with the provision of these services. Pursuant to CMS’s “Medicare Claims Processing Manual,” Pub. No. 100-04, ch. 1, § 60.1.1, providers are not required to provide beneficiaries with advance notice of charges for services that are excluded from Medicare by statute. As a result, beneficiaries may unknowingly acquire large medical bills that they are responsible for paying. In FY 2006, Medicare received over 53 million claims with a modifier GY and denied claims totaling over $400 million. We will examine patterns and trends for physicians’ and suppliers’ use of modifier GY. (OEI; 00-00-00000; expected issue date: FY 2009; new start

 Double-billing physician services furnished to hospice patients
o The OIG will review the extent of Part B billing for physician services provided to Medicare hospice beneficiaries. The regulations at 42 CFR § 418.304 list the physician services that are already covered by Medicare under the hospice benefit. The regulation provides that, for physicians employed by or in an arrangement with the hospice, payments for certain services are reimbursed to the hospice as part of the hospice payment, while other services are paid to the hospice under the Part B MPFS. Physicians may receive reimbursement for hospice services under Medicare Part A or Part B. This study is a followup to recent OIG studies on hospice care. We will determine the frequency of and total expenditures for physician services under Part A and Part B for hospice beneficiaries. We will identify whether physicians double-billed hospice services to Part A and Part B. (OEI; 00-00-00000; expected issue date: FY 2009; new start)

 Place of service errors
o The OIG will review physician coding of place of service on Medicare Part B claims for services performed in ambulatory surgical centers (ASC) and hospital outpatient departments. Federal regulations at 42 CFR § 414.22(b)(5)(i)(B) provide for different levels of payments to physicians depending on where the services are performed. Medicare pays a physician a higher amount when a service is performed in a nonfacility setting, such as a physician’s office, than it does when the service is performed in a hospital outpatient department or, with certain exceptions, in an ASC. We will determine whether physicians properly coded the places of service on claims for services provided in ASCs and hospital outpatient departments. (OAS; W-00-08-35113; various reviews; expected issue date: FY 2009; work in progress)

 Failure to follow Medicare rules for colonoscopies and sleep studies
o The OIG will review the appropriateness of Medicare payments to physicians for colonoscopy services. A colonoscopy is a complex procedure for examining the entire colon and may include, for example, biopsy to remove polyps, tumors, or other lesions or related services that the physician may deem necessary, such as medical consultations and office visits. A colonoscopy generally requires that the patient be placed under sedation in an outpatient hospital setting. The Social Security Act, § 1833(e), precludes payment to any service provider unless the provider has furnished the information necessary to determine the amounts due such provider. We will determine whether Medicare payments for colonoscopy services were properly supported, billed, and paid in accordance with Medicare requirements. (OAS; W-00-09-35221; various reviews; expected issue date: FY 2009; new start)

o The OIG will examine the appropriateness of Medicare payments for sleep studies. Sleep studies are reimbursable for patients with symptoms consistent with sleep apnea, narcolepsy, impotence, or parasomnia in accordance with the CMS “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 70. Medicare payments for polysomnography increased from $62 million in 2001 to $215 million in 2005. We will also examine the factors contributing to the rise in Medicare payments for sleep studies and assess provider compliance with Federal program requirements. (OEI; 00-00-00000; expected issue date: FY 2010; new start)

 Failure to perform face-to-face visits with patients as required for long-distance physician claims

o The OIG will review the appropriateness of Medicare claims for long-distance evaluation and management services. Pursuant to the CMS “Medicare Benefits Policy Manual,” Pub. No. 100-02, ch. 15, § 30, a service may be considered a physician’s service if the physician either examines the patient in person or is able to visualize some aspect of the patient’s condition without a third person’s judgment. Although services provided by means of a telephone call between the physician and the beneficiary may be covered under Medicare, there are certain services that require a face-to-face visit. Previous OIG work indentified instances of physicians billing for services that would normally require a face-to-face examination for beneficiaries who lived a significant distance from the physician. We will also examine factors that contribute to the submission of long-distance physician claims. (OEI; 07-08-00350; expected issue date: FY 2009; work in progress)

 Improper billing for practice expenses incurred by selected physician specialties (specialties not specified in the work plan)

o The OIG will review the actual expenses of selected physician specialties. Physician services include medical and surgical procedures, office visits, and medical consultations. Physicians are paid for services pursuant to the MPFS, which covers the major categories of costs including the physician professional cost component, malpractice costs, and practice expense. The Social Security Act, § 1848(c)(1)(B), defines “practice expense” as the portion of the resources used in furnishing the service that reflects the general categories of expenses, such as office rent, wages of personnel, and equipment. We will determine whether Medicare payments for physician services performed by selected specialties are comparable to the actual expenses incurred by the physicians in providing services and operating their practices. (OAS; W-00-09-35219; various reviews; expected issue date: FY 2009; new startFailure to properly perform all services required under the clotting factor furnishing fee

 Outpatient physical therapy services provided by independent therapists
o The OIG will review outpatient physical therapy services provided by independent therapists to determine if they are in compliance with Medicare reimbursement regulations. The Social Security Act, § 1862(a)(1)(A), provides that Medicare will not pay for items or services that are “not reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member.” CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 15, § 220.3, contains documentation requirements for therapy services. Previous OIG work has identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented. Focusing on independent therapists who have a high utilization rate for outpatient physical therapy services, we will determine whether the services that they billed to Medicare were in accordance with Federal requirements. (OAS; W-00-09-35220; various reviews; expected issue date: FY 2009; new start
 Geographic areas with a high density of independent diagnostic testing facilities,
o The OIG wll review services and billing patterns in geographic areas with high concentrations of independent diagnostic testing facilities (IDTF). An IDTF is a facility that performs diagnostic procedures and is independent of a physician’s office or hospital. It may have a fixed location or be a mobile entity, and the practitioner performing the procedures may be a non-physician. IDTFs must meet performance requirements at 42 CFR § 410.33 to obtain and maintain Medicare billing privileges. A 2006 OIG review found numerous problems with IDTFs, including noncompliance with Medicare standards and potential improper payments of $71.5 million. In areas with a high density of IDTFs, we will examine service profiles, provider profiles, beneficiary profiles, and billing patterns. (OEI; 00-00-00000; expected issue date: FY 2010; new start)

 Physician reassignment of benefits,
o The OIG will review the extent to which Medicare physicians reassign their benefits to other entities. The Social Security Act, § 1842(b)(6), prohibits physicians who provide services to Medicare beneficiaries from reassigning their right to Medicare payments to other entities, unless a specific exception applies. For example, physicians are permitted to reassign benefits to other entities enrolled in Medicare when contractual arrangements that meet certain program integrity safeguards exist between the physicians and the entities or when payments are being made to the physicians’ employers. Investigations in South Florida have revealed schemes in which fraudulent providers obtain identifying information about legitimate physicians and request reassignments on their behalf. We will examine a national sample of Medicare physicians to determine the extent to which they reassign their benefits to other entities and the extent to which the physicians are aware of their reassignments. (OEI; 07-08-00180; expected issue date: FY 2009; work in progress)

 Laboratory test unbundling by clinical laboratories
o The OIG will review the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel tests to maximize Medicare payments. Pursuant to the “Medicare Claims Processing Manual,” Pub. No. 100-04, ch. 16, § 90, to ensure the accuracy of payments, Medicare contractors must group together individual laboratory tests that clinical laboratories can perform at the same time on the same equipment and then consider the price of related profile tests. Payment for individual tests must not exceed the lower of the profile price or the total price of all the individual tests. We will determine whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days. We will also determine the extent to which the Medicare carriers have controls in place to detect and prevent inappropriate payments for laboratory tests. (OAS; W-00-09-35222; various reviews; expected issue date: FY 2010; new start)

 Patterns Related to High Utilization of Ultrasound Services
o The OIG will review services and billing patterns in geographic areas with high utilization of ultrasound services paid under the MPFS. The Social Security Act, § 1848(a)(1), establishes the MPFS as the basis for Medicare reimbursement for all physician services, including ultrasound services, and section 1862(a)(1)(A) provides that Medicare will pay for services only if they are medically necessary. In areas of high utilization of ultrasound services, we will examine service profiles, provider profiles, and beneficiary profiles. (OEI; 01-08-00100; expected issue date: FY 2009; work in progress)


What is ICD-10? (
ICD-10 is essentially “not new”. The WHO (World Health Organization) is the same organization that has copyright ownership of ICD-9 in the United States also maintains the ownership and copyright of ICD-10. ICD-10 is already in use in other areas of the world. In May of 1990 the 43rd World Health Assembly endorsed the ICD-10 classification as the latest series of nomenclature and hat stipulated the use of ICD 10 all WHO member states. However, here in the United States, ICD-10 implementation has been postponed until the year 2013. The proposed implementation date for ICD-10 in the US is October 1, 2013 and the formal adoption of the standard ICD-10 format will take place under the guidelines of the HIPAA act of 1996.
Currently the 2009 year ICD-10 version is the most current ICD-10 version available at this time, and is available for public viewing here in the US, The revisions for 2008 and 2009 have been made and can be viewed on-line at (

ICD-10 is comprised of 3 separate volumes (similar to how ICD-9 is structured) and is published and available in the six official languages of the WHO, which are English, French, Russian, Spanish, Arabic, and Chinese,) as well as in 36 other languages. ICD-10 has also has data specific versions such as ICD-O-3 International Classification of Diseases for Oncology; , ICECI, International Classification of External Causes of Injury; ICPC-2 International Classification of Primary Care, Second edition; ICD-10 for Mental and Behavioral Disorders Diagnostic Criteria for Research; and ICD-10 for Mental and Behavioral Disorders Clinical Descriptions and diagnostic Guidelines.

The ICD-10 consists of:
 Tabular lists containing cause-of-death titles and codes
(Volume 1);
 Inclusion and exclusion terms for cause-of-death titles
(Volume 1);
 Alphabetical index to diseases and nature of injury, external causes of injury, table of drugs and chemicals (Volume 3),
 Description, guidelines, and coding rules (Volume 2).

ICD-10-PCS is the procedure coding system that is being developed as a replacement for ICD-9-CM, Volume 3. ICD-10-CM is the new diagnosis coding system that is being developed as a replacement for ICD-9-CM, Volumes 1 & 2. ICD-10-CM is very similar to ICD-9-CM. The guidelines, conventions, rules, and organization of the code sets are very similar to what you are currently using to in ICD-9-CM. Most coders should be able to transition to coding ICD-10-CM with a minimal amount of training. .
In ICD-10-CM a single code can be found to report a disease and its current manifestation (i.e., type II diabetes with diabetic retinopathy). In fracture care, the codes differentiate an encounter for an initial fracture; follow-up of fracture healing normally; follow-up with fracture, mal-union or nonunion; or follow-up for late effects of a fracture. In addition, ICD-10-CM the trimester in obstetrical coding is now able to be designated.

The major differences between the two ICD systems are in how it will affect information technology and software at your practice/facility and the guidelines set forth by the HIPPA transactions and code sets implemented here in the USA back in 1999.

In ICD-9-CM there are approximately 13,600 codes as standard numeric code sets, plus the “E” &”V” codes. Valid ICD-9 CM codes have 3, 4 or 5 digits. ICD-10-CM code sets configure aproximately 120,000 codes. All the codes are alpha-numeric beginning with a letter and with a mix of numbers and letters. Valid code sets for ICD-10-CM can utilize 3, 4, 5, 6 and 7 digits to obtain the correct amount of specificity required to describe the diagnosis or procedure to the highest degree of specificity.

In Figure 6-4 You can see the 2007 code-set table. Within each code-set block the codes expand out for the most available specificity utilizing both Alpha and Numeric indicators. According to the WHO All major changes that were scheduled for 2009 have been postponed to 2010. These changes have now been implemented and can be found at the WHO website

ICD-10-PCS is the procedure coding system that will take the place of ICD9 volume 3, for reporting of inpatient procedures. This system is based on a seven-character, alphanumeric code using the digits 0 to 9, and the letters A-H, J-N, P-Z. The general principles of ICD10PCS is that the diagnostic information is not included in the code descriptions, a NEC or “not elsewhere classified” option is not allowed, and all substantially different procedures are defined. However, there is a limited option for reporting of NOS or not otherwise specified codes. The common accepted definition of a NOS code is referred to as a general body part, approach or base/root operation, and the level of specificity is not available in the medical record or cannot be further clarified or obtained. (i.e. the body part “lung” is used, and the lobe of the lung is not specified)

As stated above, all ICD-10 codes can be up to 7 characters long. Within ICD-10-PCS all codes will be represented by 7 characters. Individual units for each character are represented by an Alpha or numeric unit also known as a “value”. There are 34 possible values for each character. The digits 0-9 and the letters A-H, J-N, and P-Z. Held within the system structure are 16 separate sections:
1. Medical and Surgical
2. Obstetrics
3. Placement
4. Administration
5. Measuring and Monitoring
6. Extracorporeal Assistance and Performance
7. Extracorporeal Therapies
8. Osteopathic
9. Other Procedures
10. Chiropractic
11. Imaging
12. Nuclear Medicine
13. Radiation Oncology
14. Physicial rehabilitation and Diagnostic Audiology
15. Mental Health
16. Substance Abuse and Treatment

As you can see in Figure 6-6 the ICD-10-PCS table contains 4 columns and varying rows. The columns specifiy the allowable values for characters 4-7 and the rows specify the valid combination of the values.
The coding curve for ICD-10-CM will be very steep for existing coders who procedure code from the current ICD-9-PCS system. (volume 3). Our traditional code-set that we are accustomed to using is now expanded to the 7 character format and has become extremely complex and specific.

As a coding manager, this will be a huge educational requirement for all coding staff to become proficient in this format of coding. With the additional time prior to implementation, it would be adviseable to begin the educational process with your coders to start learning and understanding the ICD-10 PCS coding guidelines and conventions.

Knowing that we have a bit more time, allows you as the manager, to implement this educational re-training into your standard coder education for your department. In addition to re-training your coders, you will also have to re-educate your ancillary staff and physicians/providers in this system too. If possible, you should integrate the educational processes by taking a currently coded ICD-9-PCS code, and having the coder “re-code” it into an ICD-10-PCS format.

Any kind of change is difficult, but as your coders become more and more familiar with the ICD-10-PCS format, the easier it will be for you and your staff to embrace ICD-10-PCS when it is implemented in 2013.



Ethics in Medical Coding? What is a code of ethics? A code of ethics is a set of guidelines designed to set parameters of behavior for a particular group or association. Most organizations will govern themselves, but in the area of sensitive issues, a code of ethics will set the standard of the behavior you want the members to exhibit and live up to. Most ethical standard guidelines dedicate themselves to handle issues such as confidentiality, privacy, use (or mis-use) of specific or proprietary information. A code of ethics s hould be clear, concise and easy to follow. It should also embody specific protocols and beliefs of the organizations’ mission and values. Ethics are kind of like morals and common sense. It is what you think is right or wrong, and. being "ethical" means trying to be reasonable and doing what you think is right. In it’s simplest form, ethics are the actions we take to accomplish what we perceive is the greater good. Many times we look at ethics as “what (it) should be” not necessarily “what (it) is”.

Most people operate on a level of feelings and awareness, and most ethics and ethical decision making is derived upon how we are feeling emotionally that day. So, everyone in the world will have a differing view of what the term ‘ethics” really means. Most people, if confronted with an ethical dilemma, revert to their feelings and they person moral core belief. Amazingly enough these beliefs are usually rooted in common sense and are among the social norms put out by society. The most difficult ethical dilemma coders face, is to maintain privacy, security, and confidentiality of the medical record content that they have access to, within the scope of their work. A physician or medical provider of care, will face the ethical challenges of providing care and treatment to a demographic of people/patients that have the right to accept or refuse care, may have a alternative lifestyle, religious affiliation, or criminal past that is radically different from the provider of care. How difficult it must be to have a patient refuse care, even though it may mean the patient will ultimately die, based upon their decision to refuse care. It is those ethical dilemmas that we as coders bear witness to, as the reader and interpreter of the medical record.

In the coding world, the AAPC (American Academy of Professional Coders) has a code of ethics that certified members must attest to, and acknowledge that they support. This code of ethics can be found on their website at Their code of ethics is only applicable to those members of the AAPC. In addition to the members of the AAPC, this also includes members who have a credential that is certified by the AAPC. If you fail to adhere to their specific code of ethics, they state they can revoke your credential and membership. Within the AAPC’s code of ethics, they reference a code of ethical standards for members to promote and maintain, in regard to service and conduct by its members. In addition, this code of ethics also requires the member to be dedicated to the highest standard of professional coding and billing services for employers, clients and patients. However, the term highest standard is not qualified or quantified. Therefore, the adherence of this code of ethics would be subject to interpretation, if a complaint were filed, or you were found to be non-compliant with their code of ethics. Interestingly, the AAPC has an on-line form that can be submitted if a member feels another member has violated these standards.

AHIMA (American Health Information Management Association) also expects their members to adhere to a formal Standards of Ethical Coding, and a formal Code of Ethics. Both sets of these guiding principles are applied uniformly to their members. AHIMA’s code of ethics is available on their web site, AHIMA’s Code of Ethics references the fact that coders are frequently faced with ethical challenges. They also expect that coders themselves and coding managers will adhere to AHIMA’s expectations when making decisions regarding diagnosis and procedural references of patient care through the practice of medical coding. AHIMA also references the term integrity, and that they expect not only a member making an ethical decision, but to demonstrate integry during the application of the coding processes, regardless of what codes are being reported.

AHIMA’s Standards of Ethical Coding outlines 11 bullets that coders should abide by. This latest revision was approved by AHIMA’s house of Delegates in September of 2008. If your staff is a member of AHIMA, it would be a good time to have them review this document, as there have been changes made that may impact your coder(s). AHIMA has then taken the ethics standards one step further. In addition to the Code of Ethics, and the Standards of Ethical Coding, AHIMA has created a working guideline of how to interpret the Standards of Ethical Coding. This working interpretation helps clarify the guidelines by utilizing examples of behaviors and situations that the coder may be presented with. Of course, no one document can cover all situations or have a comprehensive list of all situations that a coder would face, but it gives the coder a working tool from which to refer to when having to make a difficult ethics based coding decision.

As a coding manager, you may have staff that are not members of AAPC or AHIMA, so you will have to determine if you should create a code of ethics for your own department or practice. Why have a code of ethics? You might want to consider these ideas in your decision making process:

 Do you want/need to define acceptable behavior within your department or practice?
 Do you want to promote your expectation(s) of high-standards of coding/billing practices, protocols or policies?
 Do you want to set a benchmark of personal standard for self-evaluation?
 Do you want to set a standard to be upheld, to promote awareness of your department or practice within your medical practice, facility, or medical community?
Now, if you’ve decided to incorporate a Code of Ethics, you may want to follow AHIMA’s path, and include a document for the Standards of Ethics, and a guideline for which the standard(s) is to be interpreted. Once you have these criteria put to paper, you should have all your employees (including yourself) sign an attestation that they have read, understand and agree to this Code of Ethics. Then, you will also need to include the enforcement area of the document. You will need to state what will happen if the Code of Ethics is violated, e.g. possible termination, demotion, etc…

As you are developing your Code of Ethics, customize this document for your particular practice or department. Involve your employees in the process. All of your employees will have a differing view of ethics, but with a team effort, a good solid core of standards should be easily identified. Once written, plan an education process and an on-going review and update process. Times change, and so do the issues that come up in a coding department. Be sure that you keep your Ethics of Coding relevant to the immediate concerns, and that all changes are agreed upon, and updated into the document in a regular and on-going process.
A favorite quote of mine regarding ethics comes from Aristotle…"But we must remember that good laws, if they are not obeyed, do not constitute good government. Hence there are two parts of good government; one is the actual obedience of citizens to the laws, the other part is the goodness of the laws which they obey..." (Aristotle, Politics 1294a3-6).

Contracting and Negotiating w/Insurance Payers

If you’re lucky, you work as a coding manager for a company that employs a medical services or medical staff employee who is a specialist in contracts and negotiations with insurance and 3rd party payrors. If your like most of us.. You have to do the contract negotiations yourself. I had the opportunity to work with an insurance contract specialist, and they gave me some insight into what qualifications make them so good at what they do.

In the perfect world you would have either an employee or designated legal counsel who can step into this role as an insurance and contract negotiator. They embody skills such as experience in \computer systems development, application and maintenance from a user perspective, extensive knowledge of health care delivery systems, with particular emphasis on billing for medical services and payment methodologies, physician and hospital coding practices. In addidtion having experience from a payer perspective. They also have a good working knowledge of medical terminology and regulations pertaining to HMOs, PPO’s, Medicare and Medicaid. Most important is the ability to effectively communicate both verbally and in writing with parties who may have conflicting interests and different interpretation, topped off with skill in conflict resolution and meeting facilitation.

Since most of us don’t get to live in the perfect coding world, we have to learn to negotiate these contracts by ourselves. The payer contracts that you negotiate are the key to your revenue stream. You want to made sure that you can identify potential underpayment ploys, and negotiate a contract that is going to strengthen your revenue stream, yet be acceptable for the payor too. In these situations, you want the most dollars for your practice, and the insurance carrier, wants to pay you the least amount of dollars that they can.

Practices who routinely audit their claims against what their contracts state, have noted that up to 20% of those claims submitted correctly were paid incorrectly. When you have a 20% incorrect reimbursement rate back from the payer, that will ultimately impact you and your bottom line in time and effort spend to track the error(s) and have them rectified, then paid back out appropriately. No one wants to spend precious time and effort doing appeals that should have never happened in the first place.

As the coding manager, utilize your coding software to identify these “underpayment errors”. Make sure that the front end edits are catching the simple coding errors, such as missing modifiers and mis-matched diagnosis. Also, use your software to pre-load your anticipated reimbursement from the payor, and when the reimbursements are keyed back into the system, any aberration from the anticipated reimbursement amounts should flag out onto an error report for review. You may not want to use this for all claims, but you definitely want to see if this can be managed with your top 10 or 15 high dollar procedures that are commonly utilized at your practice. Don’t spend a lot of time on a high-dollar procedure that is only performed once or twice per year. Then choose the next 10 or 15 most commonly provided procedures (such as your E&M claims) and have the software pull out the same data for the E&M.
If you find that the payer is routinely reimbursing you incorrectly, you will want to look at your contract with the payor and bring to their attention that they are violating the terms of the contract, and you want to rectify the situation. In addition, make sure that you are appealing each and every claim that was paid inappropriately within your specified contract guidelines. If you only have 120 days to file an appeal, make sure that appeal is out within the 120 day deadline.
As you appeal this contract, clearly define the reimbursement criteria that was set forth. Define the payment policies, what you have agreed to as appropriate payment including “carve outs”, global fees and global fee periods (i.e. 0, 10 90 days global fee periods) multiple surgery reduction percentages, modifier multipliers, bundling edits, place of service differentials, and supplies/pharmaceutical and drug claims.

In your analysis of your contracts with your non-government payers, you should anticipate seeing the government payers reimbursing at the standard rate for the Medicare Fee Schedule that is applicable for your state. Your highest dollar fee for service contracts should be paying you between 30% to 50% more that what is on the Medicare Fee Schedule. If you audit and find you have payers that are paying below the Medicare fee schedule, you need to contact them and re-negotiate. A good rule of thumb is that your government contracts such as Medicare, Medicaid, Tricare, etc should routinely be the base rate for what you are negotiating our other contracts against.

Within your insurance contracts you should have a good case mix of high and low reimbursement rate contracts for your services. Keep in mind though, what you get reimbursed, should not be a factor against what your office/facility fee schedule charges for those services. If you set your fee schedule to be same as your anticipated reimbursement rate, you have limited your opportunity to charge and bill your services based upon the current market trend rate amounts.
You will also want to look at contracts that may not bring in a huge amount of reimbursement, but they may bring in a dedicated population of patient referral. If you are the only practice in the area that accepts ABC insurance, as the preferred provider of care, you may be able to then grow your practice based upon the new load of patient directed traffic to your facility. This can work in your favor. You may have negotiated a specific reimbursement rate for a specific amount of time, but when that contract is up for renewal, request a higher percentage of reimbursement, based upon the fact that you have now provided optimal care for their pool of patient load.

Keep in mind as you negotiate contracts with an insurance company, they will be utilizing their legal team to be written in their benefit. So you need to make sure that you have either really good knowledge of contracts and contract negotiation, or have the contract looked at by your own legal staff, or legal counsel. You should also have the contract looked at by your CEO/CFO and get their buy in on it too.
Listed below is a quick down and dirty listing of the essential elements of what should be included within an insurance payer contract:

• Review the parties and notice if any “all products” clauses are contained within the contract.

These type of clauses define who the players are. Many insurance carriers offer multiple products such as HMO, PPO, EPO, Medicare, Medicaid, etc. Read the contract closely to see if you’ve agreed to be a provider for one of these products, or if you’ve agreed to provide services for all of the product line. This is not uncommon to find this type of “bait and switch” in insurance payer contracts..

• Be clear on the contract definitions.

Every insurance payer contract should have a definition section. This is often overlooked in the contract but is very important. This is where you will find the payers definition and interpretation for medical necessity, which bundling edits they may or may not use, covered services, or modifier application are listed.
• Scrutinize the policy and procedures manual.

It is not uncommon for a contract to include additional information by merely referring to it in “the agreement.” This additional information (the notorious “policies and procedures”) may include some very important information. Have the insurance carrier provide you with a copy of that policy and procedure manual before you sign the contract.

• Ensure mutual understanding on the effective dates.

The final contract should designate a specific date that the agreement will become effective. Be wary if there is verbiage that refers to an “event time-frame” that the contract becomes effective (e.g. when credentials are verified) versus a static “date time frame” (e.g. 11/01/2009) Clearly define the effective date as noted in the contract. Do not provide services prior to the effective date. The only caveat to this is if you have another agreement clause as to the reimbursement of those claims made prior to the effective date of this contract

• Be aware of a “hold harmless or indemnification” provision. T
This is one of those things that can be financially dangerous to you. It’s a provision you should fight to have removed from the contract, but you may have to accept it if you want the contract. A “hold harmless or indemnification provision” means that if you are sued and the insurance carrier is brought into the legal proceedings you (the provider) are responsible for the insurance carriers costs.

What should happen if you are in a contract and need to terminate, or the contract has an automatic renewal? Unless there is gross violation of the contractual agreement, you will probably not be able to terminate the contract prior to its expiration date. If you find that there is a gross violation on the payors part, you will need to seek legal counsel to begin a contract termination. Most contracts do have some type of contract termination verbiage contained within them. Be wary of a contract that states the insurance carrier has the discretion to terminate the contract “without cause”, “with cause”, or for “immediate termination for cause”. If any of this verbiage is in the contract, be sure that you negotiate to have the same right to terminate, and that it is spelled out clearly within the defined limitation of what “cause” may or may not be. (again this may need to be spelled out in the definition section of the contract)

Never sign a contract that has an automatic renewal clause. As an ongoing part of your managerial duties, contracts with all insurance carriers need to be reviewed and renewed on a year to year basis. As a manager, try and have all your insurance contracts come up for renewal around the same time as your budget process or fiscal year start dates. If you renew your contracts around the same time as the budgetary processes, you will be able to factor in any increases or decreases in anticipated revenue from those payers into your fiscal budget. And last but not least…. When in doubt, just say NO, to a bad contract!

Coding Manager Handbook Ch 5 Revenue

**The Revenue Cycle
**The Appeal Process
**The Budget

As a manager, you will find that the basis for office and hospital medical coding services, is the revenue process. Most physician practices are revenue based and are part of a “for profit” business model. Some practices are part of a hospital system that are included in the “not for profit” business model. The for profit vs. the not for profit practices do have variances regarding how they are set up with tax structures etc..., However, both have many similarities involved in the oversight of the monetary flow. I have always thought of the monetary processes as a stream or river when the money flows consistently with some ups and downs, but is constantly moving forward. You want to avoid those occasions where the flow of revenue falls to a trickle, or has been impeded for what ever reason.

A good revenue cycle or revenue flow process depends on all team members working together effectively and communicating if there is a problem or issue within the cycle. This is an on-going process for the clinic or hospital facility. Within the revenue cycle are these functions are:

1. Patient accesses the system

2. Schedules an appointment with the Patient Services Representative

a. Verification of insurance
b. Authorization and certification to see provider
c. Pre-registration gathering of demographics
d. Identification of referring physicians or consultants
e. Patient is informed of the referral process, and instructed to bring all insurance cards and co- payment amounts

3. The registration forms are filled out and consents signed

a. Hands on verification of insurance at time of services, ensure that pre-authorizations are on-file
b. Review all demographic information with the patient 1-1
c. Collect co-pay as appropriate

4. Patient meets with the provider for care of documented services

a. Patient is seen and examined regarding identified medical concerns ro problems
b. Procedures are performed and/or treatment prescribed or initiated
c. Final diagnosis is noted
d. Physician or provider of care documents the services rendered within the medical chart/record. This is to be appropriate and correct and informative for the patient.

5. The documentation is reviewed and coded

a. The services documented by the physician or provider is reviewed by the coder to accurately reflect services utilizing CPT, ICD-9 and HCPCS codes.
b. Documentation is completed and signed off by the physician or provider

6. The charges are keyed and processed

a. Keyers and coders enter the data into the patient management system to include all fees .
b. Claims software scrubs the entries for correctness
c. Charges are to be entered in a timely manner for prompt payment by 3rd party payers.

7. Claims and statements are produced

a. Claims are created and edited to be complete and correct (an additional scrub)
b. Claims are then sent electronically to the payer, or the clearinghouse daily.
c. Goal is to have 100% of all claims go electronically initially. Only appeal claims should go out via a paper process
d. Billing statements are sent out to patients with a self pay balance

8. Payment is processed by the 3rd party payor or by the patient
a. Electronically and manually key and post all monies received from payers and patients.
b. Manually key the denials, rejections and or adjustments as per what is noted on the remittance advice from the 3rd party payers
c. Create and document any and all refunds to be sent back to 3rd party payers or patients. All refund activities should be processes within a designated time frame (such as 1 week, once per month etc)
d. Reconcile all charges, payments and adjustments at the end of the day, or within a 24 hour time period.

9. If not paid, the claim goes back out for re-submission and appeal
a. Review all remittance advice, for rejections.
b. Make all coding and charge corrections (if warranted by documentation)
c. Correct any demographic errors, or missing referral/pre-authorization numbers
d. Review bundling edits and adjustments

10. Secondary claim is filed (if necessary)
a. Have coding department submit claim to secondary/tertiary payers. The goal for this should be within 1 week of receiving initial claim. Most Medicare plans will automatically medi-gap the claim to the secondary/tertiary payers.
b. If initial claim is rejected, have appeal letter created, and submit with appropriate documentation and forms
c. Re-submit and appeal with hard paper copy, or via electronic submission if possible.
d. Follow up on all re-submitted claims within a 30,45,60 timeframe process. If goes to 75 days, move to self pay balance ledger.

11. Follow up with the patient (if necessary)
a. Initiate in-house collection call for self pay accounts within 30,45,60 day periods
b. Create payment arrangements or a budget plan for outstanding balances that exceed XXX dollars.

12. Claim sent to collections (if necessary) Legal processes
a. Consider sending bad debt to a collection agency
b. Review garnishments of wages
c. Review liens on property
d. Formal collection processes through the court system (small claims, etc)

As you can see from the above format, that when there are problems or issues within the revenue cycle stream, your payments and accounts receivable will suffer. Of course, if the dollars are not coming in the door, then you will struggle to meet your accounts payable obligations. As the coding manager, you are an integral part of this process. You need to be willing to learn each and every part of this process, and enable it to keep working smoothly.

The revenue cycle in the office practice and the hospital realm are very similar. As the coding manager, you may be responsible for any or all of these above processes depending how large the practice is. Some of the pitfalls of this cycle are high deductibles, or self pay patients, charitable contributions, peaks and valleys such as cold and flu season, holiday seasons, restrictive processes such as pre-authorizations and referral issues. Your front desk personnel should be well versed in collection of co-pays and revenue collections.

Within the revenue cycle, you need to make sure that your electronic claims submissions follow the most current protocol and use the most current forms that are available. Currently CMS requires physician practices to file claims on a CMS 1500 form, and facilities for file claims on a UB-04 (aka CMS 1450)
If you are unsure of the criteria to fill out the CMS 1500 or the UB-04, CMS has explicit instructions on the website for the criteria needed to fill out the forms. (For Medicare CMS-1500 form completion and coding instructions, see Chapter 26 of the Medicare Claims Processing Manual (Pub.100-04), For Medicare CMS-1450/UB-04 completion and coding instructions see Chapter 25 of the Medicare Claims processing Manual (Pub.100-04). The UB-04 will be the only hardcopy claims format accepted by CMS after May 22, 2007.) Your medical management software should have the electronic versions of the CMS 1500 form and the UB-04 already encoded within it. However, you should know the criteria needed to complete the forms correctly.

It is important that you know the ins and out of these claim forms. Your department may be the one who does the secondary claims filing, or files hard-copy claims with 3rd party payers. You may be lucky enough that you have an information services (IT) department who handles this.

Now that the forms are filled out, direct submission to 3rd party payors is next, or your usage of a claims clearing house may be implemented by your practice or facility. You may or may not know what a medical claims clearing house is. It is “data repository” and re-filing of such data that is transmitted from you to 3rd party payors. Some clearing houses not only offers claim submissions, but also provide ancillary services such as

 Electronic patient eligibility inquiry
 Prior Authorization and Referral authorization processes
 Patient address verification
 Patient credit and history verification
 Claim submissions
 Claim status inquiry
 Electronic remittance advice
 Patient statements (for both self pay and balances after 3rd party payor revenue receipt

The clearinghouse that you use should integrate seamlessly with your medical practice software, for easy submission to/from the clearinghouse. In addition, they should have a 95% or higher successful clean claim submission guarantee to you in writing. They should also offer secondary or tertiary electronic submission of claims. The ideal situation, is that upon successful sending of the electronic data you should anticipate payment via electronic remittance advice between 10 and 15 working days. Outlined below, shows the progression of how the clearing house works

1. Create an electronic file of charges keyed by the coder or data entry staff
2. You upload this file to the clearing house via secure encoded data transmission files
3. The clearing house then scrubs the claim checking for errors.
4. If error free, it will then transmit your data file to the specified payer.
5. If there are error present, the clearing house will inform you of the error, and you then have the opportunity to go in on-line and make corrections to that particular claim.
6. Once corrected you can re-submit.
7. If all claims rec’d are correct, the 3rd party payer will process those claims, and return a reimbursement check back to you via your bank if you have direct deposit, or with a formal reimbursement check. An explanation of benefits will accompany any financial remittance.

This is an ideal set up, especially if your coding/keying staff are on the ball, you can key the charges on and within 2 -3 weeks have reimbursement for those charges back in the door to your practice. Other benefits of a clearing house, is that you can fix your errors in minutes rather than days or weeks down the road after you receive your remittance advice. You should ultimately have fewer rejected claims, as the initial scrub process should take care of that initially. You should also be able to reduce the amount of paper, envelopes, postage etc, but utilizing the data for on-line submission, rather than paper format.

The EOB and remittance advice will be coming back to you much more quickly via an electronic submission, rather than paper submission by hand. Once you have that EOB in your office, you will need to have this information keyed on to the patient’s account via the single line-item process functionality. This ensures that the correct payment correlates with each line item as was submitted initially on the CMS 1500. There are many different companies that offer electronic claims submission, These companies all have to file the claims based upon HIPPA data and transaction criteria. The price for these services varies too, so you will want to do a thorough investigation of what these companies offer versus what the cost is to have the claims submitted to really get a good picture of the expense to your practice/facility. Just because the company may “charge” a higher price, may not mean you are getting a better product or service. Do the work and investigate throroughly before signing any type of financial commitment to the clearing house.
Now that you’ve submitted your claims, you should receive back a data file that is also HIPAA compliant. With the implementation of the HIPAA national standards, a listing of remittance advice remark and claim adjustment reason codes are available through the internet at CMS also has put up a web site that can walk you through the search function of the remark codes, or you can view them all. WPC assists several organizations in the maintenance and distribution of HIPAA-related code lists external to the X12 family of standards. Each of the lists have different release schedules. These committees maintain the integrity of the HIPAA transaction and code sets. The National Uniform Claim Committee , maintains the health care provider taxonomy code set, by the Centers for Medicare and Medicaid Services maintain the remittance advice remark codes, and the Insurance Business Process Application Error Code Maintenance Committee maintains the insurance business process application error codes.
If you are lucky, your claims have gone through cleanly and have been paid in a timely manner. Unfortunately, you will always have claims that error out, or need to go through an appeals process.

The appeals process is a necessary evil. When a claim is denied, and you have to appeal, it costs you in time, effort and money. You now have to utilize your employees to gathering everything together, writing an effective appeal letter, sending accompanying documentation that the claim should be paid, then re-filing via a paper claim. So now, instead of having the revenue back to you within 10-14 business days, it has now been delayed up to 6-8 weeks before you may even hear from the 3rd party payor. If you are lucky, you will get a favorable response to your appeal, and you’ll have your payment within 6-8 weeks.

When choosing to appeal a claim, you will want to make sure that you are appealing the non-payment decision for all the right reasons. If you are appealing a claim for a bundling edit, make sure that the correct modifiers are on the claim, and that the procedures should be paid separately and unbundled. Your documentation from the provider for the procedure should clearly spell this out. Otherwise, you’ll receive another denial- and probably correct that the procedures were not separately identifiable.

Tracking your medical claim reimbursements is vitally important to the revenue cycle too. When your data entry keyers and auditors are posting the monies to the accounts, train them to look at the reimbursement and evaluate if you are getting paid correctly for the services. Ask the questions, were you reimbursed correctly? Were the claims processed properly?. Do you have a set fee schedule with specific payors, and was the claim paid out correctly to you? Always review your contracts, and make sure that your employee have access to copies of those contracts as well. If the payor is operating outside of your contract, you may, in fact, be due more money than they have been paying you. When reviewing your claims reimbursements look at these areas.

 100% reimbursement. This may look like a good thing, but chances are it’s not! The carrier may have reimbursed you below the set fee schedule. Did you bill the carrier below what they are willing to pay as a maximum amount on a specific CPT code? Always review your fee schedule and what you have contracted with the pay for specific CPT codes. Never sign a contract unless the specifics are spelled out in regard to reimbursement by the carrier per CPT code.

 The Explanation of Benefit (EOB) shows no payment made. There may be a couple of reasons for this. There may be a coding issue (such as modifier, bundling edit etc) or the patient may not have coverage from the carrier at this time. Verify with the coder and the payor if re-sending a claim that is in a “new coding year” determine if the payor wants the correct code for that specific CPT /ICD9 year, or does the payor want you to bill with the “new coding year” codes? Most insurance companies want attached documentation, and that documentation should support medical necessity on each and every claim submitted.

 If your EOB shows a large contractual adjustment, or has a reason code for a reduced payment rate you should verify that the claim was submitted with the correct information. If the wrong place of service code (POS) was coded that can reduce your payment, also missing modifiers, or inappropriate modifiers appended to the CPT codes can affect the payment processes. Look carefully too, as the payor may have reduced payment, if the pre-authorization was not obtained prior to the services being performed. Another area for error is in the CCI bundling edits. Always have your coders double check the bundling edits. Do not unbundled the services and expect separate payment, unless you have the documentation to prove that the procedure was separately identifiable, and should be unbundled.

Claim denial can happen for nearly any reason. Denials are caused by usually human error, and are not intentionally fraudulent in nature. However, in this age of HIPAA, CMS and the OIG are looking for any way possible to safeguard the payment processes for the government. These entities are charged to audit the payment process for the Medicare and Medicaid systems, and will find any means to reduce or deny your claim within the government boundaries CMS has implemented audit type programs prior to paying claims, and will request full documentation on a small sample (1 or 2 claims) to ensure correct coding and billing.

CMS also conducts post payment audits of a random 10 charts. If they feel there is sufficient evidence of incorrect billing, or possible fraudulent billing, they will escalate their audit process, and do a formal inquiry into an entities formal billing processes. Most physicians and providers have denials simply due to human error. I’ve listed below many common payment denials reasons from payers. If you can cleanly submit your claims on a regular basis, you will consistently reap the reward of continuous revenue flow.

Common Payer Denial reasons:
 Patient Demographic Information is incorrect on the claim. Avoid using characters such as asterisks, dashes, slashes, periods, commas etc on the claim form. Many electronic data software programs cannot recognize these notations, and the clearing house, or payor will reject the claim as unrecognizable. The claim will then be rejected and returned back to you without being received by the payor, It is up to you to review the rejected claim, correct the claim (i.e remove the dashes, slashes, periods, commas) and resubmit. Do not add any dashes in the patients insurance member IDS, or with a social security number, do not add periods to the address information, (e.g. P.O. Box # type in as POB or PO Box)

 Non-Coverage or Terminated Coverage , or Member is not found on file at the time of service. If your front office staff has performed an initial authorization for eligibility of service, and your claim is denied for this reason, call the carrier themselves, and get a re-verification. Then double check your software to ensure the information was entered into your computer system accurately. Make any necessary changes, and resubmit your claim.

 Pre-authorization or Certification not on file, No referral on file. If your practice did not obtain pre-certification , pre-authorization or have a referral from the patient’s primary care physician, claim approval and or payment for services, procedures or injections, will be denied. There are few instances where you can obtain retro-service approval for payment. Most often you will have to absorb the cost of these rendered services, and your patient will not be held financially liable. The EOB will state that the patient’s liability is zero, and the physician cannot bill you for the balance.

 CPT/ICD-9/HCPCS issues. Make sure that your staff is using the correct years’ codes, that 5th digits are correct, modifiers are appended to the correct service code, in the correct sequence, bundling edits have been reviewed and are adhered to. Incorrect use of the modifier can be one to review closely. If the procedure is not a bilateral procedure, do not append a bilateral modifier. Look carefully and educate your coding staff to ensure that RT, LT, TC and 26 modifiers are used correctly. Modifiers 59, 22, 52, 53, 99 require documentation be sent to the insurance payor, prior to being paid. Be prepared to re-submit the claim to the carrier with the documentation to support the modifier, or medical necessity via paper claim once you receive this type of denial. The carrier may be willing to have you fax or electronically file this data to them to expedite your claim.

 Internal software system errors such as a missing UPIN or NDC number, or physician ID numbers incorrectly input into your billing software, or missing provider, or facility information on the claim. These claims will be rejected. You may have to enlist the help of your IT/IS department to help clear these issues up prior to resubmission of your claims.

 Some claims will be denied for a third party liability marker. If the claim involves workman’s compensation, or auto accidents those claims should be sent to those payors, and NOT to the patient’s medical or dental insurance carrier. Some of these medical/dental carriers will reject the claim up-front if specific accident codes (such as 800/900 series ICD9 diagnoses) are denoted on the claim form, and the no TPL is not on file within the claim. Some accidents that occur at the patient’s home should be sent to the medical carrier, but get rejected too. In those instances, you will need to appeal with the correct documentation showing that the accident occurred at the patient’s home, and is not subject to payment from a 3rd party liability payor such as workman’s comp, or an auto accident policy.

 Be sure to file your claim within the timely filing deadline. Many of your contract will specify that the claims have to be submitted within a certain number of days or months. CMS, Medicaid programs, and major medical insurance carriers all have specific timely filing criteria. You need to educate your staff regarding these timeframes. If you have filed the claim within the timely filing timeframe and have to appeal be sure to track when the initial claim was submitted, denied and re-billed. Again, you may have to enlist the help of the IT/IS department to see if there is a tracking/documentation system within your submission software to show when the initial claim was filed, if the payer or clearing house received the claim and the documentation of the initial rejection via the EOB, so you can appeal if necessary. If you have to submit a claim via paper, be sure to send it via certified mail, or have it sent via an independent courier system (such as FED-X, UPS, etc) so you can have accurate tracing documentation of the submission of the claim, and receipt by the carrier.

If you find that you have to perform the formal appeal process, keep in mind these steps to expedite your claim for payment of the denied services.

 Claim Information: Determine from the EOB the specific denial reason or remark codes used to adjudicate your claim. You have the right to request information as to the criteria they used to deny your claim. (such as the payer utilizes a specific encoder software edit system, that denied your claim, or they do not recognize or have a contract with your practice or facility).

 Write your appeal letter: Make sure that you are within the timely filing deadline for appealing the claim. If you are be sure that you have made copies of all pertinent information to file back with your claim form. This appeal packet will include

o A copy of the initial denial letter
o A copy of the original EOB showing the denial
o A copy of the patients insurance card
o A copy of the pre-authorization, certification, referral
o A copy of the medical record documentation showing medical necessity
o A copy of the contract you have with the payer (if needed)
o A clean copy of the CMS1500 or UB-04 claim form

 The formal written appeal letter should state what you want to have happen with this denial

o Clearly describe the service, procedure or injection that you want covered

o Clearly describe what you want the carrier to do (such as re-review the operative report, explain why the modifier(s) used are correct and why etc)

o Include your name, your facility or practice name, and where and when you can be contacted. Include the patient’s name, policy number and copy of the patient’s insurance card if possible with your appeal information.

o State why you want this to happen. If your health plan states in their policy that you must have tried A, B, C and D first, then make sure you have tried A, B, C and D. Then, support your description with medical records to show how you tried A, B, C and D. Include any ancillary services such as x-rays, MRI’s or lab tests that were done too.

o Explicitly explain why you feel they adjudicated your claim in error, and what your expectation is to remedy the situation. i.e. You adjudicated the modifier 50 in error, as this was a bilateral procedure, so I anticipate payment from you at 150% of the standard fee schedule, or that they erroneously bundled procedure abc123 with procedure def567.

o State the time frame for which you expect a written confirmation or re-adjudication. i.e. I expect to have written confirmation from you in regard to this situation within 10 business days.

o Last but not least…. Review your letter for spelling errors. Re-read your letter to ensure that it clearly states what you want to have happen. That it includes all pertinent documentation and the timeframe for when you want the carrier to resolve this issue. Be sure to keep a copy of what you have sent to the carrier in a separate file for your audit documentation procedure and protocol.

Audit Processes

The audit process can encompass many different areas. For physician based practices you will look to an audit process to ensure that the claim you billed, matches the documentation in the medical record. There are numerous tools that you can use to verify that the E&M code billed matches the claim on your CMS 1500 claim form. The ultimate goal is that the physician documents the services provided to the patient accurately within the medical record, the coder accurately bills for the service to the 3rd party payor, the 3rd party payor sends you a check for the services rendered.

However, life rarely works this easily. CMS and the OIG want to ensure that physicians are documenting and billing correctly for the services provided, AND that those services were medically necessary. The cost of healthcare and physician time is a huge concern. Patients feel the “sticker shock” of the cost of healthcare when they see what a 15 minute visit with the provider costs. Then the patient also has to contend with the overall cost of their insurance, in addition to an increase in premius, deductibles, co-pays, and then the skyrocketing costs of medications. But on the flip-side, physicians and providers also face similar circumstances. The physicians face increasing overhead costs of employee salaries, decreased reimbursement from private payers, and overall operational expenses. The trend is more self-pay patients due to job losses and lay-offs, patients are more critically ill when seeking care, some resort to non-compliance of maintenance medications due to the expense.

It is always a good idea to look at how your staff is performing and do a quick but comprehensive overall office audit. This way as the coding manager, you can get a good handle on what areas may be needing some TLC from you. I have included a generic physician office audit template that will give you a broad idea of areas that need some attention. You can quickly go through this by yourself, or enlist others in your department to help out with it too. I feel that if all take part in the process, then all can be a part of the solution to any problems you may encounter.

If you are noticing a drop or dely in your revenue stream, the self audit should be the first place to start. You really need to evaluate which type of audit will work best for you in your particular situation.

1. Review your Fee slip/Superbill/Encounter sheet. Have the coder review to ensure all CPT, ICD9 and HCPCS codes are correct and for the current year.

2. Do a “top-10” procedures audit. Run a report showing the 10 ten procedures performed in your office, and verify that the documentation in the medical record matches what was billed.

3. Audit your medical records to verify that signatures, consents, waivers, and ancillary reports are on filed, and correctly filed within the chart.

4. Follow up appeals audit. Look at the denied claims that you have appealed and formulate a percentage of those that were successful appeals vs/unsuccessful appeals to the carriers.

5. Have your coding staff implement a routine on-going audit process within the department. If the medical record documentation if dictated or on-line, have the coding staff compare the completed fee slip/superbill/encounter sheet that the provider fills out, against what the provider has documented in the medical record. Coding by documentation is always better, than “assuming” that what the physician noted on the superbill was correct. The coder can also ensure that the correct sequencing of the diagnosis codes is correct. Mine for any procedures that were inadvertently missed by the provider’s documentation on the fee slip. The coder also has the opportunity to add/subtract and make other coding corrections prior to the claim being sent.

Coding by documentation is always the best way to ensure correct claims are going out the door. But if you do not have dictation on-line, and have to wait for hard copy, you may want to consider doing periodic random audits of your charts. A 10-chart audit of each physician should be performed every month. Track the outcomes of these audits, and educate and follow up on any trends that you see happening. With just a few of these suggestions aabove, you may be able to increase your revenue flow quickly and easily.

What happens if CMS or the OIG want to see what is happening in your billing and medical records? What should you do? CMS has been charged by the federal government to be the custodial parent of the taxpayer dollars being paid to providers through the Medicare and Medicaid programs. They are trying to ensure that providers are putting forth a reasonable effort for maintaining proper billing practices, and ethical medical practice standards of care. However, there have been providers and entities that have committed Fraud and/or Abuse by filing false and/or inaccurate medical claims solely for the purse of obtaining additional health care benefit payments and reimbursements from federal government programs.
The majority of physicians and medical providers perform within the scope of ethical practice. If errors are found, they are most often, human caused errors. Not a willful or intentional fraudulent act. Lean on your compliance plan and your risk management department to help with maintaining an ongoing self-audit practice and plan.

If you are subject to a governmental audit, seeking counsel from your risk management team, and also your legal counsel is always a wise idea.


Just as you audit your medical records, your billing records and office processes, you should also audit your budgeting processes. Most medical practices and hospitals have a firm budget process in place, but as a new coding manager, you may want to have a “mini budget” for yourself and your department, or you may be charged with handling the entire budget for the practice.

The sample budget template gives you a quick look at all the areas within a practice to know where your revenue is coming in at (Accounts recieveable) , and also being disbursed to (Accounts Payable) and the ability to track your ancillary expenses. As the manager, you truly need to be a good steward of the financial resources that are entrusted to you by the physicians and the patients.

Physician compensation will also play a big part of how financially successful your physician office is. Physicians can be compensated for their work in a number of ways. In addition to the actual salary physician receive, other ancillary benefits such as pensions, 401K, medical savings accounts, employee medical, dental and vision insurance benefits, paid time off, holiday pay, and on-going medical education credit, malpractice insurance premium payments, or even bonus incentives.

Today, most physician compensation is based upon a salary, net or gross revenue , but some packages include the bonus or incentive component. Again, as the coding department manager, you will probably not be the one to oversee these issues, but it is a good idea to educate yourself on the policies of how physicians are compensated within your organization.


 Independently contracted physician services (such as a locum tenens)
 Employee physician/provider services, paid as an hourly employee
 Employee physician/provider services paid as a salaried employee
 Contracted physician service compensated by percentage of monies collected within the A/R after expenses
 Contracted physician service compensated by RBRVS/RVU, (aka physician based patient encounter credits based on cpt worked service units)

 Other types of reimbursement/payments or incentives.