Compliant Billing
What is code linkage and what is it's purpose
Code linkage is the connection between a billed service and a diagnosis. Payers analyze this
to evaluate whether the reported charges are medically necessary and therefore should be
paid.
What does CCI stand for
Correct Coding Initiative
What is capitation?
fixed prepayment that covers the plan members services for a specific time period (think: per member/per month)
Who uses the RBRVS system of payment?
Medicare
A formal examination or review of the practices billing/coding practices
Audit
List the two types of compliance errors. (hint: one is honest/simple, one is deliberate)
fraud and abuse
What does RVU stand for?
Relative Value Unit
What is professional courtesy?
Professional courtesy means that a physician has chosen to waive (not collect) the charges for services to other physicians and their families.
What are the two main fee schedule methods used by payers?( hint: _________based and ___________ based)
Charge based - same as others in the area for similiar service, training, and experience
Resource Based - compares 3 factors :how difficult, how much overhead, relative risk
A private payer, or a government investigators review of selected records of a practice to check for compliance
external audit
What single modifier can be linked to Medicares XS, XE, and XU Modifiers?
-59
What does RBRVS stand for?
Resource based relative value scale
A payer never pays more than the _________ charge
Allowed
If the payers allowed charge for a tonsillectomy is $750 and the surgeon submits a bill for $500 for a members tonsillectomy, how much will the payer pay?
$500
Routine audits performed by the practice periodically without reason to think a compliance problem exists
internal audit
What are the three modifiers that are especially important for compliant billing?
25, 59, 91
What does UCR stand for?
Usual, customary, and reasonable
What is another term for allowed charge?
contracted fee schedule
What are the three main methods payers use to pay providers?
Allowed Charges
Contracted Fee Schedule
Capitation
The term used when a provider bills the patient for the difference between a their higher fee and a lower allowed charge
balance billing
List 5 of the 9 frequent errors related to the billing practice
non covered services
overlimit services
unbundling
inappropriate modifier/lack thereof
same level of E/M every service
consult instead of office visit
invalid/outdated codes
up or down coding
no proper signatures on file
What does GPCI stand for
geographic practice cost index
define "usual fees"
Usual fees are defined as those that they charge to most of their patients most of the time under typical conditions. There are valid exceptions to a physician’s fee schedule.
Under the capitation method; how are non covered services paid?
The patient can be billed for the service using the providers usual rate. Plans often require the provider to notify the patient in advance that the service is not covered and that the patient will be financial responsible for the full cost.
Medicares national policy on correct coding, which is an ongoing process to standardize bundled codes and control improper coding that would lead to inappropriate payment for Medicare claims
CCI