chapter 10: Coding Compliance Programs, Clinical Documentation Improvement, and Coding for Medical Necessity

chapter 10: Coding Compliance Programs, Clinical Documentation Improvement, and Coding for Medical Necessity Coding compliance - ANSWER conformity to established coding guidelines and regulations = developed to ensure coding accuracy and conformance with guidelines and regulations Coding compliance programs - ANSWER developed by health information management departments and similar areas, such as the coding and billing section of a physician's practice, to ensure coding accuracy and conformance with guidelines and regulations; includes written policies and procedures, routine coding audits and monitoring (internal and external), and compliance-based education and training. Written policies and procedures - ANSWER updated at least annually, and address clinical documentation improvement, downcoding/unbundling/upcoding, ethical coding, physician queries, using code editing software, and so on. Routine coding audits and monitoring - ANSWER both internal (performed by coding manager) and external (conducted by outside consulting agency), identify coding errors and at-risk coding practices. Benchmarking is a helpful practice that allows the coding manager to establish criteria (e.g., coding error rates, coding productivity rates), which are used during coding assessment. Compliance-based education and training - ANSWER results from routine coding audits and monitoring. Education and training programs are developed to assist coders improve accuracy (e.g., decrease coding error rates) and the proper use of software (e.g., outpatient code editor). compliance program guidance - ANSWER documents published by the DHHS OIG to encourage the development and use of internal controls by health care organizations (e.g., hospitals) for the purpose of monitoring adherence to applicable statutes, regulations, and program requirements. The comprehensive error rate testing (CERT) program - ANSWER implemented as a result of the Improper Payments Elimination and Recovery Improvement Act (IPERIA) of 2012, and its purpose is to annually review programs to improve efforts to reduce and recover improper payments. Improper payments - ANSWER those that should not have been made or included an incorrect amount. They are both overpayments and underpayments, and include: -Duplicate payments -Payments for an incorrect amount -Payments for an ineligible service -Payments for services not received -Payments to an ineligible recipient The goal of the Medicare medical review (MR) program is to____________ - ANSWER reduce payment errors by identifying and addressing provider billing errors that involve coverage and coding issues. All medical review activities are based on the operational principle of _____________, which involves data analysis, error detection, validation of errors, provider education, determination of review type, sampling claims, and payment recovery. - ANSWER progressive correct action (PCA) Additional documentation request (ADR) - ANSWER initiated when the Medicare administrative contractor has reviewed documentation submitted with a claim and then requests additional documentation from the provider when deemed necessary and in accordance with Medicare program manuals. National Coverage Determinations (NCDs) - ANSWER rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations (LCDs). Local Coverage Determinations (LCD) - ANSWER formerly called local medical review policy (LMRP); Medicare administrative contractors create edits for national coverage determination rules that are called LCDs. Which organization implemented the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control the improper assignment of codes that result in inappropriate reimbursement of Medicare Part B claims? - ANSWER The Centers for Medicare and Medicaid Services (CMS) procedure-to-procedure (PTP) code pair edits - ANSWER automated prepayment NCCI edits that prevent improper payment when certain codes are submitted together for Medicare Part B covered services. medically unlikely edits (MUEs) - ANSWER used to compare units of service (UOS) with CPT and HCPCS level II codes report