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issues related to compliance in the realm of coding Reply to each Peer about their post.

issues related to compliance in the realm of coding Reply 1 to Paolo:

Compliance plays an indispensable role in guaranteeing the protection of healthcare payments systems from fraud, waste, and abuse. According to Abbey (2010), compliance in healthcare reimbursement generally falls under statutory or contractual compliance. Statutory compliance pertains to government programs such as Medicare or Medicaid, while contractual are the HMO and PPO providers (Abbey, 2010). In specific instances, general compliance is applicable when there is no third-party payor involved and the relationship is directly between the patient and the provider (Abbey, 2010).

When dealing with compliance, issues and concern are certain to be encountered. Specifically, medical coding issues are commonly associated with medical necessity, claim filing versus claim payment, and supporting documentation (Abbey, 2010). Consequently, one of the primary errors that predispose providers in committing medical coding errors is brough about by missing or inadequate documentation. According to the MedicalBillingandCoding.org (2020), leaving out important information regarding a procedure or treatment may lead to other coding errors such as upcoding and downcoding or not coding at the highest specificity. This therefore establishes the importance of providing accurate information to avoid coding errors.

Key to addressing or mitigating coding errors is through establishing a robust compliance program focusing on coding, billing, and reimbursement. Abbey (2010) provided the seven (7) principles of a comprehensive compliance program. At the heart of this is the requirement for employee training. A provider with trained and knowledgeable employees with have a much easier path to sustained compliance.

Reference:

Abbey, D. (2010). Healthcare payment systems: An introduction. Boca Raton, FL: Productivity Press.

MedicalBillingandCoding.org. (2020). 4.03: Common problems in medical coding. https://www.medicalbillingandcoding.org/common-problems-coding/

issues related to compliance in the realm of coding Reply to Yanira :

Hello everyone,

For this week’s discussion, we’re discussing the issues related to compliance in the realm of coding and we’re also discussing the organization remains in compliance. Is really important for the organization to follow all protocols for the facility to remain in compliance and the insurance companies can keep a contract with the facility. Is really important also for the organization or facility to understand that by following all the requirements, the organization can keep its compliance certification and the insurance will pay the facility and doctors’ services. (Abbey,2010) “Although the main classifications for coding, billing, and reimbursement compliance generally involves statutory compliance for programs such as Medicare and then contractual compliance with a wide variety of private TPPs, there is also a general or default compliance level.” When coding the insurances, the provider office must provide the proper CPT codes and diagnosis codes when billing the insurance companies, to make sure they are billing, and their billing is actually accurate. These are very easy mistakes that are usually seen regularly in the medical organization/facilities.

Reference:

Abbey, D. (2010). Healthcare payment systems: An introduction. Boca Raton, FL: Productivity Press.