BILLING & CODING TOOLS
- Understanding the billing process and billing terminology
- Current reference materials
- Written policies and procedures covering billing protocol from insurance contractors
- ICD-9-CM diagnosis coding expertise (ICD-10 as of 10/1/2014)
- Well-designed patient information form or EMR (patient demographics)
- Understanding the insurance claims process
- Understanding the Health Insurance Portability and Accountability Act (HIPAA) and how it relates to claims processing
WHAT PAYERS WANT: DOCUMENTATION PRINCIPLES & MEDICAL NECESSITY
- The site of service
- Medical necessity and appropriateness of the diagnostic
- Therapeutic services provided
- Information that the services provided have been accurately reported
REVALUATING EVALUATION & MANAGEMENT CODING
- What are the elements of an evaluation and management code
- Getting paid for what you do
CLAIMS APPEALS: A KEY TO REIMBURSEMENT
- Implementing processes for appeals
- Determining an auditing staff
- Collection reports in determining appeals
- Appeals with EMR
- Understanding the explanation of benefits and remittance advice
- Proof of timely filing
- Developing an appeal letter
UNDERSTANDING FEDERAL AGENCIES THAT AUDIT
- Main governmental agencies auditing
- What is a CMS medical review?
- Components of a Medicare review
- Understanding national coverage determinations
- CERT, RAC, ZPIC, Medicaid Integrity Contractors
- Medicare Administrative Contractors
AUDITING MEDICAL RECORDS
- Medicare data banks
- Goals for an audit
- Types of audits
- DATA mining: predictive analysis
- CMS targets
- Documentation principles
DEFINING FRAUD & ABUSE
- False Claims Act
- Anti-Kickback Statutes
- Physician Self-Referral Law
- Medicare’s Fraud and Abuse Partnerships
- Office of Inspector General and HEAT program
WHAT IS MEDICAL NECESSITY?
- Medical necessity: the deciding factor in claims payment
- Medicare definition of medical necessity
- AMA definition of medical necessity
- Diagnoses frequently monitored for medical necessity
CREATING A COMPLIANCE PLAN
- OIG Guidelines
- Following the OIG work plan for auditing
- Compliance education
- Developing a compliance plan for your business office
PROPOSED CMS CHANGES FOR 2014
- OPPS payment changes
- IPPS payment changes
ICD-10: A PREVIEW
- Structure
- Principles of ICD-10
- Training for ICD-10
- Impact on ICD-10 in your IT departments
- Physician impact
- Character meaning