Mitigating The Risks And Factors Involved In Physician Practice Compliance

Years ago, OIG issued guidelines for physician practice compliance but in spite of that many practices have failed to imply a proactive and efficient system to implement it and stay compliant. But if this step is incorporated at a time when rules and guidelines are changing, there is immense scope of scrutiny and reducing staff, the practice will be immensely benefitted.

On the other hand, practices must keep with the present guidelines to impart high quality patient care, profit, and overcome audits. Receiving adequate training and being aware of all the developments can help to follow federal guidelines and steer clear of auditors and costly fines. This can be achieved by adhering to some basic recommendations for areas like:

• Privacy, meaningful use and security
• Clinical code and coding
• High quality data reporting

The American Recovery and Reinvestment Act are responsible to promote IT related to health.  In fact, the HITECH act has assigned huge sums of money for meaningful use of HER systems. Additionally, HITECH also has modified HIPAA to take critical care of privacy and security of patient information. Although physicians wait to benefit from the new guidelines, they need to be prepared to implement and comply with all the changes related to HIPAA or face penalties. Practices that feel that it is not important to incorporate the meaningful use program need to meet all the factors by 2014 or face severe penalties at the beginning of the year 2015. HIPAA privacy and security compliance will be under close scrutiny and practices need to be aware of it. So physicians cannot afford to take HIPAA compliance lightly. They must implement fool-proof protocols to steer clear of audits and denials.

The ultimate responsibility lies with the physician for all the actions performed by the staff members. If a charge cannot be validated by a practice, it should not be billed. With stringent compliance measures, physicians hold great liability and are under immense pressure to take up issues that will be a result of incorrect coding. In order to tackle this situation, a proactive approach is required along with correct documentation that will save time and revenue.

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E/M Auditing For Compliance: Ensure That You Are Compliant With The Documentation Guidelines

The regulatory and compliance guidelines are making their presence felt in the ever-changing environment of coding and billing so, physicians are making efforts to minimize the risk of audits. As an example, it can be said that MACs often review E/M services and any provider using targeted E/M codes are prone to audits. It is essential to keep in mind a few guidelines for E/M auditing for compliance 2014.

In order to determine the risk for an audit, it is essential to compare the use of E/M codes by the provider to other physicians. CMS publishes utilization data of Medicare Part B every year to ease comparison.

One can also review the service volume. Apart from the service type distribution that has been billed by the physician, the volume of the services offered can also lead to audits. In order to determine if the physician faces any risk, a comparison of the total annual revenue to specialty standards can be done. This information is available through MGMA and other organizations as well that are involved in gathering data and publishing reports. There are various percentiles and any provider ranking in the higher percentile group is an easy target for audits.

One also needs to analyze physicians. Usage can be separate from revenue and there is average level of service for a specialty, services need to be coded accordingly. Differences in utilization can be due to various mixes of patients, sub-specialization, increased productivity or marketed service areas. But at the same time, improper coding can be cited as a reason to high usage along with false claims and inflated documentation.

To make coding and billing compliant, it is important to understand how accurate physician coding needs to be. At the centre of every corporate compliance plan lies a truly effective auditing program. By pairing ones auditing program to highlight the auditing measures of other prominent payers one can reduce risk and ensure compliance.

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Follow These Tips To Build A Rewarding Career In Medical Coding And Billing

A career in medical coding and medical billing is quickly emerging to be the most sought after one. A medical coder is a general or specialty specific trained SME who uses ICD-9-CM, ICD-10-CM, CPT®codes, or HCPCS codes to report services performed by doctors or healthcare providers to patients. The service imparted gets documented in the patient’s medical record and after reviewing it the medical coder assigns appropriate codes and medical biller claims reimbursement in the form of invoices.

Doctors and healthcare providers depend greatly on medical coders and billers. But one needs to be highly knowledgeable and build a solid foundation to ensure a rewarding career or business. Here are a few tips that one has to keep in mind when starting your career:

• Adequate training: To become a certified coder, there are various programs offered on campus and online. While some are excellent and deliver what they claim, most of them fail to offer adequate coaching. These courses also differ in duration, cost and outcome. So what can be suitable for one may not work for someone else. Hence, you should always ensure you get trained from a reliable organization to help you get your degree or diploma.
• Certification: Certification is crucial if you want to be a part of a reputed organization or work with an established medical provider. Make sure you are well acquainted with what benefits and limitations your certification holds for you.
• Recognized Certification: Having a recognized certification not only gives you that extra edge but also helps you to land a job easily as almost all employers demand certified coders and have their own set of standards.
• Understand what your employer wants: There are innumerable career choices for any coder. The basic factor that will help to get a better job is to understand and equip yourself with all the educational requirements and meeting the expectations of potential employers.
• Tech Friendly: With technology being an integral part of the healthcare industry, you must be well trained and familiar to ensure error-free claims and also save time and efficiency.

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Understand what to do beyond ASC Coding and Billing For Maximum Reimbursement

Learn some basic tricks to make reimbursement quick and easy and ensure you don’t leave money on the table or face denials. Follow these recommendations from industry experts to improve profits for ambulatory surgery center.

• It is advisable to be on good terms with commercial payers. Investing in good relations over the years will ensure easy reimbursements even during difficult years. Being familiar makes your interactions and negotiations easy, honest and friendly.
• When any claim gets denied, one needs to be aggressive about it and question for reasons about its denial. According to experts, electronic claim rejection reports must be reviewed daily for ASC coding and billing error and help understand the reason for claim rejection as this leads to loss in revenue.

Also when a report is reviewed, it helps to understand if the reason for denial was due to in-house or clearinghouse or trading partner. Likewise, billing managers can train staff to improve the coding and billing process and lessen chances of in-house errors. One can also discuss errors with clearing house or trading partner to make them aware of possible reasons for denial of claims.

• It is essential to follow a standard process for hiring. All the qualities required for the position must be revised from time to time to pick the right candidate. Also, a centre will incur less charges to retain an employee than hire a new one. Cross training is also essential to enable staff for multi-tasking thereby saving costs.
• Even the most insignificant costs must be taken into consideration and added up. Often surgery center officials ignore this fact but these in the long run add up to massive amounts. Tracking small expenses can also help to save dollars.
• One must always cater to what the surgeon requires. To keep your ambulatory surgery center profitable your surgeons must be content so that they will make an effort to bring in more cases to your facility.

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Ensure A Smooth Transition To ICD-10 For Radiology By Preparing For The Documentation Changes Now

According to experts, every practice must start preparing themselves for the ICD-10 transition next year. To make this learning process hassle-free new strategies need to be introduced as performing, testing, planning and training will take great time and effort.

Amongst all the other things, radiologists need to understand the condition of the patient to correctly report it for coding and billing. ICD-10 will be a lot more detailed than ICD-9 codes so after the physician examines a patient and sends the report to the radiologist, who will in turn have a better understanding of the patient condition. This also means that for accurate billing radiologists need the history of the patient to make billing, dictation, and billing smooth and error-free.

Also, document specification is another aspect that will be required in ICD-10 for radiology. Moreover, coding will vary based on whether the procedure is outpatient or inpatient. For inpatient exams and procedures ICD-10 PCS codes are to be used. But since one exam can be performed on the same patient twice, for instance: as inpatient and then as outpatient, the report codes need to be different to mark the difference. There are also three specific sections in ICD-10 for radiology, so radiologists need to accurately pinpoint the images and the type of imaging that is being performed.

Codes in ICD-10 for radiology should be matched correctly with CPT codes. In billing, if correct codes are not reported, then it leads to loss in revenue because of inadequate information. In order to overcome this, radiologists need to be in constant communication with referring physicians. Referring physicians provide vital information like writing orders and stating the reason for the exam, so radiologists need to have a good rapport with them. This will help radiologists to bill correctly with complete information that they receive from the referring physicians. A radiologist can face serious issues if a referring office is unable to provide necessary information or is not incorporating new codes and reporting guidelines. At a time of financial crisis, being outdated will only result in compliance issues and heavy monetary losses that will affect radiologists as well as the practice greatly.

To ensure that the work of the radiologist mainly billing is effortless, one has to make sure that the referring physician is well acquainted with ICD-10. In fact, one can also offer help to enable them to train for ICD-10. ICD-10 will be introduced in order to highlight and report detailed and improved data reporting related to everything in a practice, but one needs to prepare thoroughly and ensure that their referral is adequately trained and equipped to implement all the changes. This will help to cut-out loss in revenue and costly audits. As has been stated by CMS, to ensure that your practice stays compliant, you need to start preparing for the ICD-10 transition now.

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Understand E/M coding guidelines for 1995 and 1997 to ensure a compliant orthopedic practice

Insurance carriers closely scrutinize services related to Evaluation and Management as documenting these services requires one to follow innumerable guidelines. The two basic guidelines of 1995 and 1997 have a huge impact on the way claims are being reported that effects reimbursement too.

It is important to have extensive medical billing and coding training to understand the documentation requirements to file error-free claims.
Example: In orthopedic practice, if one has to bill for a comprehensive exam, according to the 95 guideline what body area or organ does one need to address. Can body areas and organ systems be mixed when elements for the exam will be counted.

Solution: The physician has to decide the organ system and body should be examined. Every medical record is scrutinized for reasonable and medically necessary services, so it is the duty of the provider to execute the work and based on it decide what level of service needs to be billed. The physician’s clinical judgment determines the extent of the exam performed and documented the nature of the problem and the medical necessity of the case.

In the 1995 E/M guidelines, the multi organ system physical examination has been stated and in the 1997 guidelines, the general multi system and single organ system examinations have been stated. Also in the 1997 guidelines, musculoskeletal examination has been mentioned and the physician may determine the bullet points in the examination charts.

The 1997 Exam rules are well-defined and makes following the rules quite easy giving confidence before any audit. According to an auditor, this is a good way to define Exam Level by the bullets. An essential thing is that physicians should use exam templates which contain the most clinically relevant bullets, whereas the 1995 Exam guidelines lack such solid guidelines.

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