Chapter 7
Visit Charges & Compliant Billing
OT 232
OT 232 Ch 7 lecture 1
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Compliant Billing
• C0mpliance?
– Actions that satisfy official guidelines & requirements
• Correct claims report the connection between a
billed service & diagnosis
– Code linkage
• A clean claim will get the maximum amount of
money in fast with no additional work
• Consequences of non-compliance?
– Box on 207
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Knowledge of Billing Rules
• Must keep up-t0-date!
– Insurance companies have bulletins, websites, etc.
• Easier in a specialized office because less to
track
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Medicare Regulations:
The Correct Coding Initiative
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CCI
National policy on correct coding
Come from CMS
Controls improper coding that would lead to
inappropriate payment
• Updated quarterly
• Has thousands of code combos called CCI edits
that check claims via computers
– Apply to claims that bill for more than one procedure
for the same patient on the same day by same
provider
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CCI (cont’d.)
• Also tests for unbundling
– Incorrect billing practice of breaking a package of
services into component parts & reporting them
separately
• Requires physicians to report only the more
extensive version of the procedure performed
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Organization of CCI edits
• Column 1/Column 2 Code Pairs
– Checks for unbundling
– Col 1 includes all services described by Col 2
– Medicare pays for Col 1
– Software available to help check beforehand
(Billing Tip, pg 211)
– Ex pg 209
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Organization of CCI edits (cont’d.)
• Mutually Exclusive Code Edits
– MEC
– Also uses 2 columns
– Cannot be billed together
– Medicare pays lower-paid
– Ex pg 210
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Organization of CCI edits (cont’d.)
• Modifier Indicators
– Control modifier use to avoid CCI edits
• Modifiers show particular circumstances related to a
code on a claim
– 1 – modifier may be used for special circumstance
• Adjudicator will assess
– 0 – no deal
– 9 – original edit was a mistake; resubmit for
payment if appropriate
– Ex pg 211
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Medically Unlikely Edits
• MUEs
• Unit-of-service edits that check for clerical or
software-based coding or billing errors
• Established by CMS to reduce error rates
• Initial set is based on anatomical
considerations
– Hysterectomy on a male
• Will also reject billings in excess of Medicare
allowances
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Other Government Billing
Regulations
• The OIG Work Plan
– Issued annually as part of Medicare Fraud and Abuse
Initiative
– Lists projects for sampling particular types of billing to
determine whether there are problems. Practices then
study these to make sure their procedures comply with
regulations
– OIG also issues advisory opinions
• Legal advice to parties that ask specific questions
– If the asking party follows the advice, they cannot be investigated
on the matter
– Good for others to read
– OIG also summarizes findings after investigations &
publishes the LEIE
• List of Excluded Individuals/Entities
– Have been found guilty of fraud and are now excluded from work
with government
programs
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– Knowingly hiring excluded companies/people is illegal
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Private Payer Regulations
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CCI edits apply to Medicare claims only
Private payers will develop their own edits
May or may not share them
Will have to call for clarification
HIPAA Tip – pg 212
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Compliance Errors
• Payers often base their decisions to pay or
deny claims only on the diagnosis and
procedure codes
– Refers to ‘code linkage’
– The doctor must justify the procedure
– Most payers will have edits to check for this
– ‘Medical Necessity’ will vary by payer
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Errors relating to Code Linkage &
Medical Necessity
• Codes that meet medical necessity generally
meet these conditions
– The CPT procedure codes match the ICD9
diagnosis codes
– The procedures are not elective, experimental, or
nonessential
• Criteria varies by payer
– The procedures are furnished at an appropriate
level
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Errors relating to the Coding
Process
• Truncated coding
– SPECIFICITY!!!
– Billing tip, pg 213
• Gender/age mismatch
• Assumption coding, altering documentation after
services are reported, coding w/out proper
documentation
• Reporting services provided by unlicensed or
unqualified personnel
• Not satisfying the conditions of coverage of a
particular service
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Errors related to the Billing
Process
• Billing noncovered services
– If in doubt, look it up in the Schedule of Benefits
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Unbundling
Billing a consultation instead of an office visit
Billing outdated codes
‘Upcoding’ or ‘downcoding’
Billing without signatures
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Strategies for Compliance
• Carefully define bundled codes and know
global periods
– Amount of time during which all services related
to a surgical procedure are considered part of the
package and not additionally reimbursed
• Benchmark the Practice’s E/M codes with
National Averages
– Evaluation and management
– Procedure codes that cover physicians’ services
performed to determine the optimum course for
patient care
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