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

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

ISBN 9781563273681
Published April 2, 2008 by Productivity Press
230 Pages 27 B/W Illustrations

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Book Description

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.

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

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