Compliance for Coding, Billing & Reimbursement: A Systematic Approach to Developing a Comprehensive Program, 2nd Edition (Paperback) book cover

Compliance for Coding, Billing & Reimbursement

A Systematic Approach to Developing a Comprehensive Program, 2nd Edition

By Duane C. Abbey

Productivity Press

232 pages | 27 B/W Illus.

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Paperback: 9781563273681
pub: 2008-04-02
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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



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

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Management Science
MEDICAL / Health Care Delivery