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Evaluating Compliance Strategies

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    Over the years, physicians have learned that coding and billing are inextricably entwined processes. Coding provides the common language through which the physician can bill their services to third-party payers, including managed care organizations, Medicare programs, and Medicaid programs. Getting paid appropriately for services the family physician provides involves more than just coding the service and billing the third-party payer. There are aspects of reimbursement management that occur before the coding is even done and aspects long after the claim has been submitted.

    Coding appropriately is essential regardless of practice setting size. Medical practice today, more than ever before, places greater demands on physicians to see more patients, provide more complex medical services and adhere to stricter regulatory rules, leaving little time for coding and billing. Many physicians rely on office staff and billing companies to process their medical bills without ever reviewing the bills before they are submitted for payment.

    Some physicians may not be receiving the payment they deserve when they do not sufficiently oversee the medical practice’s coding and billing patterns. When medical bills are submitted with missing and incorrect information, they may result in unpaid claims and loss of revenue to physicians. Some steps to achieve accurate and appropriate medical record documentation are: •Practice timely, accurate, and complete documentation •Use appropriate diagnosis codes for examination and personal history •Link appropriate diagnosis codes with appropriate procedure codes •Use modifiers appropriately Identify other insurance coverage when billing Medicare I believe the documentation of each patient encounter should include the reason for the encounter with any relevant history, physician examination findings, prior diagnostic test results, assessments, clinical impressions, diagnoses, plan of care, date of service, and legible identity of the observer. I believe they should have more discounts for the uninsured/low-income patients. It is hard for people that are uninsured/low-income patients.

    A lot of them either cannot afford healthcare or the medications that they need, or like most cannot afford both. The HCFA 1500 claim form allows you to submit up to four ICD-9 codes, some carriers including Cigna/Medicare will only look at the first code listed for each service billed. Therefore it is very important that you link the ICD-9 code to the service. It is also critical that the data entry staff understands this concept and is linking procedures and diagnosis at charge entry.

    If the data entry staff does not link the charges and diagnosis as designated by the physician, your services may be denied. Repeatedly making incorrect diagnoses can lead to problems with the State Board. Remember, the doctor has the ultimate responsibility. Using a list full of mistakes and/or omissions is no excuse. An incorrect diagnosis followed by repeated treatments may also lead to indefensible malpractice charges. Many of the codes may be interpreted as applying to more than one area with a slightly different description relating that code to that anatomical area.

    In some cases there exists a considerable discretion as to the description, in others there is none. Only with a code book can you be sure. Coded clinical data are used in a variety of areas (e. g. health services funding) coding errors have the potential to produce consequences. The auditing process plays a critical role in the identification of causes of coding inaccuracy. A well-prepared coding and billing staff will deliver careful chart examination, accurate code selection, cleaner claims, fewer denials, and enhanced revenue.

    Staying on top of coding changes affecting their specialty is crucial to a medical coder and biller. Even a simple mistake can lead to thousands of dollars in lost revenue. Each year that passes there is more of a demand for medical services, medical supplies, medical testing, and rehab, because of this demand there is much more jobs that are available. Medical coding is one of those jobs that need many positions filled. Medicaid, Medicare and insurance companies have put many new strict guidelines that need to be followed so that the doctors can get paid.

    So this is why it’s important that an experienced individual fill these positions. The medical record should include documentation of the medical history, exam, and medical decision making involved in the treatment of a patient. The medical record serves to justify the reason for the medical care provided, with the medical necessity clearly indicated. Accurate reimbursement flows from these components. The medical record is commonly used to share information between providers and assess quality of care. Chart Audits offer a method to mprove compliance and reduce risk within a medical practice. Successful documentation improvement is achieved through education of the healthcare professional, systems and record design for facilitation of complete, accurate, timely and legible patient records. Utilizing the recommendations from the chart audit not only improves compliance with improved documentation processes but also assists in appropriate revenue capture. Chart Audits offer a method to improve compliance and reduce risk within a medical practice.

    Successful documentation improvement is achieved through education of the healthcare professional, systems and record design for facilitation of complete, accurate, timely and legible patient records. Utilizing the recommendations from the chart audit not only improves compliance with improved documentation processes but also assists in appropriate revenue capture. A payer depends on the honesty and accuracy of the people in billing and coding to present accurate information and bases their decision to pay or deny claims only on diagnosis and procedure codes, concerning allowed charges, contracted fee schedules and capitations.

    There are many errors that are made from honest mistakes. It would only make sense to want to have a uniformed compliance this way everyone would be on the same page by have simplified forms, and combining of codes that can be combined to make the billing and coding process easier. I believe it is necessary to have compliance strategies at every facility, and I support any efforts to improvements in these particular types of strategies.

    References

    Cheng, P., Gilchrist, A., Robinson, K., & Paul, L. (2009). The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding. Health Information Management Journal, 38(1), 35-46. Retrieved from EBSCOhost.

    Evaluating Compliance Strategies. (2017, Mar 09). Retrieved from https://graduateway.com/evaluating-compliance-strategies/

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