A Guide to Coding Compliance provides guidelines on performing coding compliance reviews and developing a coding compliance program. Practical and fundamental discussions on the differences between coding and billing, medical necessity, reviewing techniques, educational guides and coding compliance strategies, along with case studies based upon real experiences offer both the experienced coder and the student, with the tools necessary for handling a range of coding compliance issues. Special attention is also given to Medicare guidelines and the importance of official coding guidelines, as well as implementation of electronic health record systems and automated coding systems. For the coding and billing managers the text serves as a practical guide in answering some of the most common coding and compliance issues faced today. For students the text lays a foundation for understanding the legal requirements, payer specific instructions and the importance of quality coding.
Table of Contents
1. CODING AND BILLING – DIFFERENCES AND SIMILARITIES.
The Purpose of Coding and Billing. The Importance of Accurate Data in the Healthcare Environment. Case Studies.
2. CODING COMPLIANCE.
Defining Fraud and Abuse. Complying with Regulations. "Official" Coding Guidelines. Federal Regulations. Payer Guidelines. Coding Guidance from Professional Associations. Coding "Behavior". Standards of Ethical Coding. Exercises and Questions for Discussion.
3. THE IMPORTANCE OF DOCUMENTATION.
Documentation as the Key Resource. Documentation Standards. The Purpose of the Encounter Form. Templates. Querying – A Process Within a Process. Corrections in the Medical Record. Exercises and Questions for Discussion.
4. CODING AND MEDICAL NECESSITY.
Defining Medical Necessity. National and Local Coverage Decisions. Advance Beneficiary Notices of Noncoverage (ABNs). Billing for Medical Necessity. Coding Compliance Issues. Compliance Activities. Case Studies. Review Your Understanding.
5. DEVELOPING A CODING COMPLIANCE PROGRAM.
Integrating Coding and Corporate Compliance. Quality Coding and Accurate Claim Submission. OIG Compliance Guidelines. Developing Policies and Procedures. Staffing Coding Professionals. Exercises and Questions for Discussion.
6. AUDITING AND PREVENTION.
Assessing Areas of Risk. Sampling and Audit Methods and Design. Prospective and Retrospective Reviews. Auditing Tools. Auditing Resources. Results and Reports. Discovery. Reporting the Results. Assessing the Appropriate Preventive Measures. Education and Re-training. Benefits of a Well-Designed Program. Exercises and Questions for Discussion.
7. EMERGING TECHNOLOGIES.
Encoders – Friend or Foe? Automated Code Assignment Technology. Balancing Quality and Quantity. Case Studies.