Compliance for Coding, Billing & Reimbursement, 2nd Edition: A Systematic Approach to Developing a Comprehensive Program

While the vast majority of providers never intend to commit fraud or file false claims, complex procedures, changing regulations, and evolving technology make it nearly impossible to avoid billing errors. For example, if you play by HIPAA’s rules, a physician is a provider; however, Medicare requires that the same physician must be referred to as a supplier. Even more troubling is the need to alter claims to meet specific requirements that may conflict with national standards. Far from being a benign issue, differing guidelines can lead to false claims with financial and even criminal implications. Compliance for Coding, Billing & Reimbursement, Second Edition: A Systematic Approach to Developing a Comprehensive Program provides an organized way to deal with the complex coding, billing, and reimbursement (CBR) processes that seem to force providers to choose between being paid and being compliant. Fully revised to account for recent changes and evolving terminology, this unique and accessible resource covers statutorily based programs and contract-based relationships, as well as ways to efficiently handle those situations that do not involve formal relationships. Based on 25 years of direct client consultation and drawing on teaching techniques developed in highly successful workshops, Duane Abbey offers a logical approach to CBR compliance. Designed to facilitate efficient reimbursements that don’t run afoul of laws and regulations, this resource – Addresses the seven key elements promulgated by the OIG for any compliance program Discusses numerous types of compliance issues for all type of healthcare providers Offers access to online resources that provide continually updated information Cuts through the morass of terminology and acronyms with a comprehensive glossary Includes a CD-ROM packed with regulations and information In addition to offering salient information illustrated by case studies, Dr, Abbey provides healthcare providers and administrators, as well as consultants and attorneys, with the mindset and attitude required to meet this very real challenge with savvy, humor, and perseverance.

Table of Contents:
Introduction Overview Three levels of CBR compliance concerns CBR compliance program development Systematic approach Systems theory CBR policies, procedures, and infrastructure Preparing for external audits Information resources Conducting research Healthcare computer billing systems CBR compliance officer and team development Terminology, definitions, and acronyms Case study listing Overview of healthcare compliance Healthcare industry Health care payment systems Cost-based systems Prospective payment systems Capitated systems Healthcare delivery systems Healthcare compliance laws, rules, and regulations Statutory requirements Contractual requirements HIPAA BBA MMA DRA Compliance concerns and program development Key elements for compliance programs Compliance program areas Use of systems approach Settlement agreements Structuring CBR compliance programs CBR and seven key elements Compliance standards and procedures Coding policies and procedures Billing policies and procedures Chargemaster policies and procedures Documentation policies and procedures Utilization review policies and procedures Compliance and auditing policies and procedures Oversight responsibilities Delegation of authority Employee training Monitoring and auditing Enforcement and discipline Response and prevention CBR compliance officer Use of investigative and review teams Development of policies and procedures Facilitation and organizational development CBR and administrative decision making Coding, billing, and reimbursement: Problem/opportunity areas Identifying problem/opportunity areas Determining real problem Medical necessity False claims Service area concerns Observation status Emergency department Subacute care Non-physician providers Medicare fraud, abuse, and anti-kickback laws Chargemaster concerns Accurate information Correlation of information Chargeable, separately chargeable, billable, and separately billable items Categorization of items Charge explosion Coding interface Drugs and self-administrable drugs Non-covered items and services Special payment system requirements Charging interface APG and APC considerations OIG resources Cost reports Organizational structuring Notes Comparison of organizational structures Operational considerations Coding and payment system demands Procedure coding Diagnosis coding Revenue codes Payment systems Safe harbors Statistical and benchmark utilization Investigation and problem solving Systems approach Problem/opportunity identification Problem/opportunity analysis External solution design Internal solution design Solution development Solution implementation Solution monitoring and remediation Graphic tools Multiple perspectives Raised perspective Designing audits Fact gathering and interviewing techniques Team approach Information analysis Root cause analysis Statistical basics and graphic representation Data and relative data arrays Frequency distribution Percentages, percentiles, and proportions Measures of central tendency Index numbers Graphic examples Probability and distributions Sample sizes and confidence intervals Business process reengineering Quality improvement Benchmarking Development of CBR policies and procedures Developing and writing policies and procedures Form, format, and organization of policies and procedures Indexing and numbering Dates Approval process Distribution list Cross-referenced policies and procedures Notes and discussion Meta data Areas of concern Developing CBR compliance manuals Special publishing of policies and procedures Summary and conclusion Implementing changes Introduction Analyzing change impact Designing implementation plan Pre-implementation preparation Implementation Post-implementation monitoring Facilitation and organizational buy-in Computer technology Project planning skills and software Consultants Organization information flows Developing effective training Learning modalities Training techniques and modes of delivery Technology Lecture–recitation Developing training materials Developing and assessing training for specific audiences Logistics Training at different levels and in different languages Training trainers Learning objectives Tips for effective training Team teaching Preparation Interpersonal communications Audiovisual aids Facilitating learning Addressing resistance Prerequisites for participants Unlearning Coordinating internal and external training Recordkeeping Monitoring and corrective action Designing reviews and audits Review design Audit design Determining sample size Selecting samples RAT-STATS program of OIG Example service area considerations Home health services Emergency department Observation services Medical clinics Inpatient services Administrative area considerations Assessing personnel competencies Additional monitoring interfaces Corrective actions Documenting review and audit activities Conducting CBR baseline audits Baseline audit: Overall objective Beginning baseline audit process Designing baseline audits: Different approaches Designing baseline audits: Top-down approach Area overview Designing baseline audits: Bottom-up approach Hybrid approach Tools, techniques, and processes Utilizing payment system classification Diagnosis-related groups (DRGs) Ambulatory payment classifications (APCs) Related disciplines Integrating CBR compliance into corporate compliance Corporate compliance programs Seven fundamental principles Compliance standards and procedures Oversight responsibility Delegation of authority Employee training Monitoring and auditing Enforcement and discipline Response and prevention Specialized compliance programs Whistle blowers Managed care: Capitation compliance CBR compliance officer Chargemaster Revenue enhancement Reimbursement contracts Service area interfaces Cost reports New and expanded service areas Documentation systems Integrating CBR compliance with other compliance programs Documenting compliance activities and keeping records Record retention Investigation and subpoena response planning HIPAA compliance HIPAA privacy HIPAA transaction standard/standard code set rule Standard code sets Revenue codes Condition codes Place of service codes Standard transaction formats HIPAA security HIPAA National Provider Identifiers (NPIs) Summary and conclusions Special regulatory areas Introduction Provider-based rule (PBR) Billing privileges Emergency Medical Treatment and Labor Act (EMTALA) Emergency department levels Advance beneficiary notices (ABNs) Leaves against medical advice Non-emergency care Non-physician providers (NPPs) Stark law issues Compliance considerations for hospitals Chargemaster Static file Dynamic process Charging and charge development Special Medicare hospital designations Medical staff organization and credentialing Managed care contracts Associated entities Medical clinics: Free-standing versus provider-based Rural health clinics (RHCs) and federally qualified health centers (FQHCs) Ambulatory surgical centers (ASCs) Home health agencies (HHAs) Independent diagnostic testing facilities (IDTFs) Comprehensive outpatient rehabilitation facilities (CORFs) Special hospital programs and provider-based clinics Compliance considerations for physicians and clinics Clinic organizational structuring Physician relationships Physician ownership Non-physician providers (NPPs) Coding documentation guidelines Establishing medical necessity Claims development: CPT, modifiers, and ICD Reciprocal and locum tenens physicians Medical staff bylaw considerations Medical directorships Hospital-based clinic profitability Special compliance audits and reviews Emergency department (ED) E/M coding and billing Surgical coding and billing Modifiers Correlation of physician and hospital coding Medical necessity Cardiovascular interventional radiology Technical component E/M coding DRG and inpatient audits Standard DRG audits Inpatient audits APC audits CPT/HCPCS coding Modifier utilization Special situations and special service areas Chargemaster audits Provider-based rule (PBR) reviews General provider-based compliance Provider-based clinics Billing privileges: CMS-reviews References and bibliography Healthcare compliance organizations Healthcare-related certifications Healthcare compliance Managed care contracting Training and education Facilitation, teams, and team development Six Sigma and other quality programs Mind mapping, creative thinking, and related subjects Facilitation and interpersonal communications Auditing, statistics, and related subjects Internet, intranet, and related subjects Health Insurance Portability and Accountability Act (HIPAA) Chargemaster information Acronyms Appendices Abbey & Abbey, Consultants, Inc (AACI) websites Accompanying CD and CBR compliance research CBR compliance officer CBR compliance checklist Sample size determination Index Each chapter begins with an Introduction and concludes with a Summary and Conclusions