2nd Edition

Compliance for Coding, Billing & Reimbursement A Systematic Approach to Developing a Comprehensive Program

By Duane C. Abbey Copyright 2008
    230 Pages 27 B/W Illustrations
    by Productivity Press

    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 downloadable resources 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.

    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               
    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                
    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               
    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    
    Development of CBR policies and procedures           
    Developing and writing policies and procedures   
    Form, format, and organization of policies and procedures           
    Indexing and numbering              
    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    
    Analyzing change impact                
    Designing implementation plan            
    Pre-implementation preparation          
    Post-implementation monitoring           
    Facilitation and organizational buy-in         
    Computer technology    
    Project planning skills and software          
    Organization information flows             
    Developing effective training                 
    Learning modalities     
    Training techniques and modes of delivery      
    Developing training materials                
    Developing and assessing training for specific audiences            
    Training at different levels and in different languages              
    Training trainers       
    Learning objectives     
    Tips for effective training                
    Team teaching      
    Interpersonal communications           
    Audiovisual aids     
    Facilitating learning     
    Addressing resistance     
    Prerequisites for participants            
    Coordinating internal and external training     
    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     
    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               
    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         
    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           
    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   
    Abbey & Abbey, Consultants, Inc  (AACI) websites     
    Accompanying CD and CBR compliance research    
    CBR compliance officer     
    CBR compliance checklist              
    Sample size determination             

    Each chapter begins with an Introduction and concludes with a Summary and Conclusions


    Abbey, Duane C.