1. Visit Charges and Compliant Billing
Chapter 6
Visit Charges and Compliant Billing

3. Compliant Billing Following guidelines for correct coding Code Linkage
Necessary Treatments
Accurate and show necessity

4. Correct Coding Initiative (CCI)
Control improper coding/improper payments from Medicare
Quarterly code edits – system that checks codes
Same procedure, same day, same provider
Multiple DME from same provider, same day
Medicare billing
Rules for correct coding are published in the Federal Register published by CMS
Example: checking for reporting surgery with both incision and with scope
Checking code combinations which dx codes can be used with which procedure codes
Disallows reporting of codes that have been removed from code book
Doctors have to report more extensive code for procedures that include lesser procedures burn debridment, biopsy sizes

5. Office of Inspector General
OIG work plan
Fraud and abuse initiative
Check compliance with billing regulations
OIG fraud project found 23,000 billings for E/M services with -25 modifier used with 11055, 11056, (paring or cutting a corn or callus)
-25 is significant separately identifiable E/M b y same surgeon same day
Government Payers
OIG issues regulations for other government entities such as Medicaid and Tricare
They issue advisory opinions and audit reports that summarize findings after investigations.
11055 is one lesion
11056 is 2-4 lesions
11057 is 4 or more lesions
Modifier

6. Private Payer Regulations
Similar to CCI
Regulations found in contracts, handbooks, and bulletins
Private payer guidelines may be different from government guidelines.
An insurance company may choose to bundle codes not specified in CPT or may not accept modifiers

7. ERRORS!!!! Linkage and Necessity Truncated or assumption coding
Billing for
Noncovered services
Separate codes (unbundling)
Invalid or outdated codes
Upcoding or Downcoding
The codes used must indicate medical necessity or other documentation needs to be sent.
Examples ate on p. 204
Truncated codes: not as specific as possible. Coding unlisted diagnostic radiographic procedure
When documentation indicates it was an MRI
Assumption coding coding for things not documented but you “think” might have happened (not satisfying the condition for the code) i.e. a code that includes interpretation

8. Thinking It Through
Botox injections have been approved by the FDA as a procedure to treat spasms of the flexor muscles in the elbow, wrist and fingers. Should a payer reject a claim for this use of Botox based on lack of medical necessity?
May want to get preauthorization or send documentation proving necessity.

9. Staying Compliant
Know global periods and what is included in packaged codes
How many postop days are part of the global package?
Compare E/M codes with National averages
Use of modifiers
Know professional courtesy guidelines
Stay educated and up to date
Global period -- how long does post procedure cover? Minor procedures for Medicare days How long is the global period for procedures or operations?
Use modifier -79 for procedures not related to the surgery that take place during the global period
Comparing E/M helps evaluate codes being used. Prevent upcoding or downcoding
Professional courtesies: waiving the charges for other docs or family. Some states prohibit Medicare illegal
Discounts for uninsured and self-pay must be documented as to how patients are selected for the discounts.
OIG

10. Is coding being done properly?
Audits
Formal review
External—by private payers
Prepayment audits
Postpayment audits
Internal—by medical office
Is coding being done properly?
Monitoring the coding and billing cycle
Insurance companies or government review selected records
Code linkage, signatures, documentation, completeness
Prepayment audits: done by insurance company’s computers before adjudicating check documentation of the visit
Postpayment: after payments are made checking that bill was accurate, services were performed at level indicated
Internal: Conducted by office’s compliance officer once or twice a year to see whether billing and coding is compliant and analyze skill levels of personnel and need for additional training
Are changes and revisions of codes being implemented

11. E/M Audits
CMS/AMA Documentation Guidelines for Evaluation and Management
Tool used to reduce subjectivity in assigning level of service
Clear examples and descriptions to fit in each category
When selecting E/M codes you must know the extend and complexity of the examination and decision making
The Documentation Guidelines (p.211) help guide you to accurately coding E/M

12. Selecting an E/M Code History of Present Illness
Location
Quality of pain
Severity
Duration
Timing
Context
Modifying Factors
Associating signs and symptoms
1-3 = Problem Focus
4-8 = Extended Pp

13. Physician Fees Usual fees Fee Schedules
Usual fees charged to most of the patients most of the time under typical conditions
The range of physician fees are published in a database
Fees set by Normal ranges for fees in each geographic area, what government pays in that area

14. Payer Fee Schedule Charge-based Resource-based UCR RVS RBRVS
Usual, customary, reasonable
Resource-based
RVS
Relative value scale
RBRVS
Resource-based relative value scale
Charge-based—UCR of other providers with similar skill and experience
UCR -- May decide to pay midrange for that geographic area
Resource based – compares Medicare uses RVS
Difficulty
Office overhead
Relative risk involved
RVS—scale based on level of skill and time needed to provide service
Conversion factor used to determine payment p. 215

15. Fee-based Systems Allowable Charge by Payer
Maximum charge
Allowed amount
Contract adjustments
Patient responsibility is based on allowed amounts when going to a PAR provider
Coinsurances are based on allowed charges
When a patient goes to a PAR for a noncovered service, pt should receive the discounted insurance rate even if insurance doesn’t pay for that procedure
Several math examples on pp discuss allowed amounts and balance billing and provider adjustments

16. Consider This Allowed amount for E/M visit is $160
Provider A charges $180
Provider B charges $140
How much will Provider A collect?
$160
How much will Provider B collect?
$140

17. Medicare Allowed is $84 Provider’s usual fee is $200 Medicare pays 80%
Patient pays 20%
How much will Medicare pay?
80% of $

18. Payer pays 100% of allowable charges. Allowable is $2880
Provider A is PAR and charges $3100
Provider B is nonPAR and charges $3000
How much will payer pay to Provider A?
$ the allowed amount
How much will Provider A write off?
$ $2880 = $220
How much will payer pay to Provider B?
$2880 the allowed amount
How much will Provider B write off?
No write off The provider will balance bill the patient

19. Bundled Payments with Healthcare Reform
One payment for one episode of care
Instead of being paid more for more tests and more procedures, Healthcare Reform suggests paying a dollar amount for the episode of care
Bundling care for treatment into one payment

20. Capitation Setting cap rates Prepaid monthly payment
Demographic of patients and number of visits expected
Type of practice (Pediatrics, OBGYN, GP)
Prepaid monthly payment
Agreed upon covered services (office visits, but not surgery)
p. 222 has chart of capitation schedule

21. Collecting TOS Payments
Depends on third-party agreement
No collection for Medicaid or Workers’ Comp
Payment expectations need to be communicated when a patient signs up to be a new patient.