Developing A Coding, Billing & Reimbursement Compliance Program
Planning Notes
Developing A Coding, Billing & Reimbursement Compliance Program
Title: Developing A Coding, Billing & Reimbursement Compliance Program
Objective: To provide in-depth information, guidance and discussion on the systematic
development of a compliance program focused specifically on the documentation,
coding, billing and reimbursement process for hospitals and associated health care
providers. Development the documentation and infrastructure for such a program will be
provided. Special payment system concerns such as DRGs and APCs will be
addressed, special service provider concerns such as for medical clinics and home
health agencies will be discussed. The methodology concerning periodic audits,
baseline audits and a systematic training program will be discussed. Also, the interface
to the Corporate Compliance Program as well as current OIG activities will be included.
Upon Completion the Participants Will:
1. Understand the broad spectrum of compliance areas to which hospitals, systems,
physicians and clinics are subjected.
2. Appreciate the severity of current compliance issues, the auditing process, demand
letters, safe harbors, and the associated penalties.
3. Understand the process for developing a compliance program and process relative
to the documentation, coding, billing and reimbursement process.
4. Understand the use of the systems approach in analyzing situations, discovering
problems, performing research and resolving problems.
5. Appreciate the auditing and review process for conducting coding and billing audits
including sample size determination and selection of random samplings.
6. Appreciate the need for and content areas for developing a ‘Billing Compliance
Manual’.
5. Understand the process of developing a ‘Coding Policies & Procedures’ Manual to
address the many ongoing and developing coding issues for both hospital and
physician services.
6. Have knowledge of various information resources relative to the coding, billing and
reimbursement process.
7. Have knowledge of the development of special compliance plans for areas such as
home health, skilled nursing, durable medical equipment, and medical clinics.
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Developing A Coding, Billing & Reimbursement Compliance Program
Planning Notes
8. Have reviewed the challenges of utilizing NPPs (Non-Physician Providers) relative
to coding, billing and reimbursement compliance.
9. Understand how the Coding, Billing & Reimbursement Compliance Program
interfaces to the Corporate Compliance Program.
10. Review the various compliance areas that are currently active and those that may
become active.
11. Appreciate the special compliance concerns associated with different payment
systems including DRGs and APCs.
12. Appreciate the need for a systematic, organizational approach to analyze, assess
and take action in areas related to coding, billing and reimbursement.
13. Know how to utilize consultants and when to seek legal counsel and request legal
opinions.
14. Appreciate the need to develop explicit information flows for both administrative
and service areas.
15. Understand the role of other activities as it relates to compliance issues such as
Charge Masters, Fee Schedules, Cost Reports and associated areas.
16. Appreciate the concept of a 'Baseline Compliance Audit' and the steps to begin the
process.
17. Understand how the HIPAA code sets and transaction standards affect the
development of a coding, billing and reimbursement program.
18. Understand how to set up a compliance training program throughout the
organization.
19. Sources for further information.
Audience: All personnel involved in health care compliance and all personnel involved
in the documentation, coding, billing and reimbursement process. This includes coding
staff, billing staff, service area support staff, charge master coordinators,
reimbursement specialists, nursing supervisors, physicians, nurses as appropriate,
insurance experts, cost accountants and administrative staff as appropriate.
Method of Presentation: The primary method is Lecture-Recitation with the use of
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Developing A Coding, Billing & Reimbursement Compliance Program
Planning Notes
case studies. Interaction and questions from the audience are HIGHLY encouraged.
Course Materials: Extensive Class Notes (including copies of Overhead
Transparencies). Class Notes will include copies of selected readings and special
materials as appropriate.
Student Materials: No student materials are required. Concerns about various
compliance areas should be brought to class.
Prerequisites: A general knowledge of health care compliance and the current
activities of the OIG, DOJ, FBI and related federal agencies.
Course Times: This is a two-day workshop – 9:00 a.m. to 4:00 p.m. for each day.
Variable hours can be accommodated such as 1 st Day – 10:00 a.m. – 5:00 p.m. and 2nd
Day – 8:00 a.m. to 3:00 p.m.
Outline:
I. Introduction
A. Compliance Overview
B. Importance Of Meeting Compliance Rules & Regulations
C. Special Health Care Compliance – OIG Model Plans
D. General Business Compliance
E. Systematic Approach To Maintaining Compliance
F. Review of HIPAA, BBA 97 and BBRA 99
II. Fraudulent Practices – Coding, Billing & Reimbursement
A. Covered Versus Non-Covered Services
B. Non-Billable Services
C. Not Medically Necessary Services
D. Bundling Versus Unbundling
E. Upcoding
F. Misrepresenting
G. Mischarging
H. Misclassification
I. Other
III. Review Of OIG Model Compliance
A. Seven Key Areas For Compliance
B. Hospital
C. Home Health
D. Clinic
E. Laboratory
F. Skilled Nursing
G. Durable Medical Equipment
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Developing A Coding, Billing & Reimbursement Compliance Program
Planning Notes
IV. Developing A Coding, Billing & Reimbursement Compliance Program
A. Organizational Structure Development
B. Billing Policy Manual Development
C. Coding Policies & Procedures Manual
D. Systematic Problem Solving Techniques
E. Training Considerations
F. Audit & Review Considerations
G. CBR Baseline Compliance Audits
H. Settlement Agreement Implementation
V. Provider Based Status
A. Review Of Rules and Regulations
B. Provider-Based Entity
C. Provider-Based Status
D. Department of a Hospital
E. Qualifying and Reporting Requirements
F. Case Examples
VI. Compliance Areas Review
A. Payment System Interfaces
B. Medical Necessity
C. Coding and Modifiers
D. DRGs
E. APCs
F. Charge Master/Cost Reports
VII. Compliance Service Areas Review
A. Service Areas
B. Home Health
C. Skilled Nursing
D. Rehabilitation
E. Outpatient/Inpatient
F. Subacute/Postacute
G. Medical Clinics
H. Special Programs
IX. Conducting A Baseline Compliance Audit
A. Planning The Effort
B. Goals and Objectives
C. Top-Down Approach
D. Bottom-Up Approach
E. Quantitative versus Qualitative Methods
F. Monitoring Over Time
X. Additional Topics
A. Use Of Computer Technology
B. Interfacing To Corporate Compliance Program
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Developing A Coding, Billing & Reimbursement Compliance Program
Planning Notes
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
Addressing New Payment Systems
Preparing For Audits & Investigations
HCFA’s Correct Coding Initiative
Changes To Coding Systems
Documentation Guidelines
Developing A Knowledge Base
Using the Internet To Access Information
Sources For National Information
Use Of Consultants and Legal Counsel
Special Problem Areas
Notes:
1. This is an intensive two-day workshop emphasizing practical applications.
2. Questions submitted prior to the class are encouraged!
3. Reference materials will be made available to class participants as a part of
their notes.
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