medical coding chapter 1. chapter 1 reimbursement, hipaa, and compliance

Medical Coding Chapter 1

CHAPTER 1CHAPTER 1

REIMBURSEMENT, HIPAA, AND COMPLIANCE

Third-Party Reimbursement Issues

Third-Party Reimbursement Issues

● Each coding system plays critical role in reimbursement● Your job is to optimize payment

Your ResponsibilityYour Responsibility

● Ensure accurate coding data● Obtain correct reimbursement for services rendered● Upcoding (maximizing) is never appropriate

Population ChangingPopulation Changing

● Elderly fastest growing patient population● By 2050, 20% of the population will be the

elderly● Medicare primarily for elderly

Medicare—Getting Bigger All the Time!

Medicare—Getting Bigger All the Time!

● By 2018, national health care spending expected to reach $4.4 trillion

● Health care will continue to expand to meet enormous future demands– Job security for coders!

Basic Structure MedicareBasic Structure Medicare

● Medicare program established in 1965 – 2 parts: A and B

● Part A: Hospital insurance● Part B: Supplemental—nonhospital

– Example: Physicians’ services and medical equipment

● Part C: Medicare Advantage, health care options (Added later and formerly termed Medicare + Choice)

● Part D: Prescription drugs

Those CoveredThose Covered

● Originally established for those 65 and over

● Later disabled and permanent renal disease (end-stage or transplant) added

● Persons covered “beneficiaries”

Officiating OfficeOfficiating Office

● Department of Health and Human Services (DHHS)● Delegated to Centers for Medicare and Medicaid

Services (CMS)– CMS runs Medicare and Medicaid– CMS delegates daily operation to Medicare Administrative

Contractors (MAC)– MACs usually insurance companies

Funding for MedicareFunding for Medicare

● Social security taxes– Equal match from government

● CMS sends money to MACs● MACs handles paperwork and pays claims

Medicare Covers (Part B)Medicare Covers (Part B)

● Beneficiary pays – 20% of cost of service – + annual deductible

● Medicare pays – 80% covered services

Non-participating QIO ProvidersNon-participating QIO Providers

● Payment sent to patient● Non-QIOs receive 5% less than participating QIOs● Slower claims processing

Participating QIO ProvidersParticipating QIO Providers

● Signed agreement with MACs● Agree to accept what MACs pay as payment in full

– Accept Assignment

● Block 27 on CMS-1500

● Block 27 on CMS-1500, Accept Assignment

Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services.

Why Be a Participating Provider?

Why Be a Participating Provider?

● MACs usually do not pay charges provider submits– Significant decrease

● Participating providers receive 5% more than non-participating

More Good Reasons to Participate:

More Good Reasons to Participate:

● Check sent directly from MACs to participating provider● Faster claims processing● Provider names listed in a directory

– Sent to all beneficiaries

Part A, HospitalPart A, Hospital

● Hospitals submit charges on UB04● ICD-9-CM codes basis for payment

– MS-DRG (Medicare Severity Diagnosis Related Groups) ● More on this topic in Chapter 26

Part A, Covered In-Hospital Expenses

Part A, Covered In-Hospital Expenses

● Semiprivate room● Meals and special diets in hospital● All medically necessary services

Part A, Non-Covered In-Hospital Expenses Part A, Non-Covered

In-Hospital Expenses

● Personal convenience items ● Example:

– Slippers, TV– Non-medically necessary items

Part A, Other Covered ExpensesPart A, Other Covered Expenses

● Rehabilitation● Skilled-nursing● Some personal

convenience items for long-term illness or disabilities

● Home health visits● Hospice care ● Not automatically

covered– Must meet certain

criteria

Part B, Supplemental Part B, Supplemental

● Part B pays services and supplies not covered under Part A

● Not automatic● Beneficiaries purchase

– Pay monthly premiums

Type of Items Covered by Part BType of Items Covered by Part B

● Physicians’ services● Outpatient hospital services● Home health care● Medically necessary supplies

and equipment

Coding for Medicare Part B Services

Coding for Medicare Part B Services

● Three coding systems used to report Part B– CPT– HCPCS– ICD-9-CM (Vol. 1 & 2)

Health Insurance Portability and Accountability ActHealth Insurance Portability and Accountability Act

● Established 1996● Administrative Simplification● Largest change● Includes:

– Electronic Transactions– Privacy– Security– National Identifier Requirements (NPI)

Federal RegisterFederal Register

● Government publishes changes in laws ● Coding supervisors keep current on changes

Issues of Importance in Federal Register

Issues of Importance in Federal Register

● October contains hospital facility changes● November and December contain outpatient facility

changes and physician fee schedule

Federal RegisterFederal Register

Figure: 1.3Figure: 1.3From Federal Register, From Federal Register, August 3, 2010, Vol. 148, August 3, 2010, Vol. 148, No. 8, Proposed Rules.No. 8, Proposed Rules.

Outpatient Resource–Based Relative Value Scale

Outpatient Resource–Based Relative Value Scale

● RBRVS● Physician payment reform implemented in 1992● Paid physicians lowest of

– 1. Physician’s charge for service– 2. Physician’s customary charge– 3. Prevailing charge in locality

National Fee ScheduleNational Fee Schedule

● Replaced RBRVS● Termed Medicare Fee Schedule (MFS)● Payment 80% of MFS, after patient deductible● Used for physicians and suppliers

Relative Value UnitRelative Value Unit

● Nationally, unit values assigned to each CPT code

● Local adjustments made:1. Work and skill required

2. Overhead costs

3. Malpractice costs

Relative Value UnitRelative Value Unit

● Often referred to as fee schedule● Annually, CMS updates RVU based on national

and local factors● Beneficiary Protection

– Physician Payment Reform– Omnibus Budget Reconciliation Act of 1989– Maximum Actual Allowable Charge (MAAC) 1991

Geographic Practice Cost Index (GPCI) and Conversion Factor (CF)

Geographic Practice Cost Index (GPCI) and Conversion Factor (CF)

● GPCI: Geographic Practice Cost Index– Scale of cost variance of charge locations

Charge location may be entire state● CF: Conversion Factor

– National dollar amount – Paid on Medicare Fee Schedule basis– Converts RVUs to dollars– Updated yearly

Medicare Fraud and AbuseMedicare Fraud and Abuse

● Program established by Medicare – To decrease fraud and abuse

● Fraud – Intentional deception to benefit

Example:– Submitting for services not provided

Beneficiary SignaturesBeneficiary Signatures

● Beneficiary signatures on file– Service, charges submitted without need for patient signature

● Presents opportunity for fraud

FraudFraud

● Anyone who submits for Medicare services can be violator– Physicians– Hospitals– Laboratories– Billing services– YOU

Fraud Can BeFraud Can Be

● Billing for services not provided● Misrepresenting diagnosis● Kickbacks● Unbundling services● Falsifying medical necessity● Routine waiver of copayment

Office of the Inspector General (OIG)Office of the Inspector General (OIG)

● Each year develops work plan● Outlines monitoring Medicare program● MACs monitor those areas identified

in plan

Complaints of Fraud or AbuseComplaints of Fraud or Abuse

● Submitted orally or in writing to MACs or OIG● Allegations made by anyone against anyone● Allegations followed up by MACs

AbuseAbuse

● Generally involves– Impropriety – Lack of medical necessity for services reported

● Review takes place after claim submitted – May go back and do historic review

of claims

KickbacksKickbacks

● Bribe or rebate for referring patient for any service covered by Medicare

● Any personal gain = kickback● A felony

– Fine or – Jail or – Both

Protect YourselfProtect Yourself

● Use your common sense● Submit only truthful and accurate claims● If you are unsure about charges

– Check with physician or supervisor

Managed Health CareManaged Health Care

● Network health care providers that offer health care services under one organization

● Group hospitals, physicians, or other providers

Managed Care OrganizationsManaged Care Organizations

● Responsible for health care services to an enrolled group or person

● Coordinates various health care services● Negotiates with providers

Preferred Provider Organization (PPO)Preferred Provider Organization (PPO)

● Providers form network to offer health care services as group

● Enrollees who seek health care outside PPO pay more

Health Maintenance Organization (HMO)

Health Maintenance Organization (HMO)

● Total package health care● Out-of-pocket expenses minimal● Assigned physician acts as gatekeeper to refer patient

outside organization

Drawbacks of Managed CareDrawbacks of Managed Care

● Organization has incentive to keep patient within organization– Services provided outside organization limited – Patient must have approval to go outside organization if

services to be covered

ConclusionCHAPTER 1Conclusion

CHAPTER 1REIMBURSEMENT, HIPAA,

AND COMPLIANCE