Billing Regulations

Billing Regulations Accountable Care Organizations (ACO) - ANS is an organization working to better coordinate patient care The National Correct Coding Initiative (NCCI, or more commonly, CCI) - ANS an automated edit system to control specific Current Procedural Terminology (CPT) code pairs that can be reported on the same day. Local Coverage Determination (LCD) - ANS decision made by a Medicare Administrative Contractor (MAC) on whether a service or item necessary or reasonable, and therefore covered by Medicare within the specific region that the MAC oversees National Coverage Determination (NCD) - ANS A national coverage determination (NCD) is a United States nationwide determination of whether Medicare will pay for an item or service. Incident-to billing - ANS is a way of billing outpatient services (rendered in a physician's office located in a separate office or in an institution, or in a patient's home) Incident-to billing - ANS provided by a non-physician practitioner (NPP) such as a nurse practitioner (NP), physician assistant (PA), or other non-physician provider. Incident-to billing can be confusing () Improper coding also might occur through "unbundling" or "fragmentation. - ANS Unbundling or fragmenting billing codes illegally increases a provider's profits by billing bundled procedures separately, which results in higher reimbursement from Medicare and Medicaid. With EHR software - ANS providers can copy and paste notes from a patient's previous visit into each current treatment note, which can make it appear that the provider has diagnosed and treated every condition on that list. (EOBs) - ANS Explanation of Benefits Appeals - ANS A medical appeal for a payment is a reconsideration for payment after the patient has been billed by the physician or medical facility Appeals - ANS The appeal maybe granted by the, medical insurance, third party, physician or medical facility or it can be denied. Clearinghouses - ANS where claims are sent for payment, the clearing house is a financial institution formed to facilitate the exchange of payments, securities, or derivatives transactions. Crosswalking - ANS is the mapping of codes between the equivalent or near equivalent between different code sets Crosswalking - ANS The most crosswalking is completed between ICD-10 and ICD-9 since the changes have occurred over the years. Superbill - ANS encounter forms Retention of records - ANS is the amount of time a document must be stored with the ability to access it when needed Record retention is need for medical records - ANS based on the amount of time a document must be stored with the ability to gain access to the medical record if needed Balance billing sometimes known an extra billing - ANS is billing the patient for the difference between what the patients' health insurance chooses to reimburse for the services and what the provider charged for the service.