Physicians may be angry at the increased documentation, coding, and billing workflow and compliance activities they must perform to be successful in new reimbursement models. However, to avoid accustations of fraud and upcoding, they must develop their own OIG-recommended compliance plan and be open to rigorous feedback and advice.
Mastering hierarchical condition categories (HCC) is key to success under new reimbursement methodologies that rely on risk-adjustment, quality, and value metrics such as the Quality Payment Program (QPP). Organizations need to take a close look at their training and audit programs to ensure that valuable information isn’t being left out of documentation—and negatively impacting HCC scores.
In fiscal year 2016, 65% of providers were subject to prepayment review associated with the CMS Fraud Prevention System, according to a report by the United States Government Accountability Office (GAO).
Outsourcing some HIM functions is common at many organizations. The decision might initially be spurred by staffing shortages or budgetary concerns, but many outsourcing arrangements become long-term projects.
In the 2018 OPPS proposed rule, CMS proposed a change to the current clinical laboratory date-of-service policies for molecular pathology tests and for Advanced Diagnostic Laboratory Tests.
Improper payments can easily occur due to errors in billing, coding, or medical necessity. As such, it’s important to have a program in place to help you identify and prevent improper payments.
The specificity of ICD-10 ushered in a stronger focus on clinical coding audits. From internal reviews to external coding audits, healthcare organizations nationwide are revisiting tried-and-true audit practices with ICD-10 coding quality in mind.
Whether it is the CPT Manual or Chapter 12 of the Medicare Claims Processing Manual, the definition of a “new patient” is the same for physicians and nonphysician practitioners billing. But that doesn't mean coding and billing for E/M services is clear cut.
As CMS and third-party payers have looked for ways to treat patients in the outpatient setting and reduce inpatient volumes, CMS has used the 2-midnight rule, in addition to other methods, to treat patients as outpatients or in observation whenever possible.
