Coding Compliance Overview

Coding, billing, and compliance each have distinct roles in healthcare. One thing we have in common is we all depend on good provider documentation to operate at the top of our profession. Though we may have some overlap in our functions, we each perform different healthcare roles. Compliance reviews coding and documentation mostly through a retrospective risk lens. We compare what was documented to what was billed, to ensure our organization properly captured and reported the correct codes. We also go a step further, by then layering on compliance guidelines. There are different sets of regulations for different provider types that work with our faculty physicians. There are Teaching Physician rules to follow, as we are an academic institution. We also employ ACP (Advance Care Practitioners) such as CRNAs, NPs, PAs, CNS. ACP come with completely different guidelines, as they are billing providers. The most common rules reviewed for ACPs are “Incident-to” and Shared/ Split billing. These rules vary according to the POS (Place of Service).

Coding

A medical coder takes a patient’s health care information (medical procedures, diagnosis, necessary medical equipment, and medical services information) from the physician’s notes, and transforms this information into universal medical alphanumeric codes. There are different code sets for different services. CPT (Current Procedural Terminology) codes are used to describe procedures, mostly. The ICD-10-CM (International Classification of Diseases) manual describes conditions, status, and disease (diagnosis codes). HCPCS (Healthcare Common Procedure Coding System) describes other procedures, services, drugs, and DME. Coder abstracting is a RCM prospective billing function.

Billing

A medical biller submit claims to payers and bill patients for their financial responsibility. This is predominantly a prospective RCM (Revenue Cycle Management) function.

Compliance

Healthcare billing compliance ensures the practice plan is adhering to federal healthcare billing laws and regulations, which prohibit and prevent fraud, abuse and waste in the healthcare industry.

We all have a place in the healthcare. Whatever your role, good documentation starts with the physician and those that support them. In order to create good documentation, providers need to understand the expectation for the care they ordered, performed, and/or supervised. Our goal is to place as many coding, billing, and compliance resources at your fingertips so that you can quickly provide feedback and education regarding medical documentation.

Most asked provider question

Why are my E/M codes being downcoded? Which is a perfectly valid question. But not if the purpose for the meeting scheduled is for training with your compliance team. Sure, we down-code in audit, but the question is mostly commonly asked as a result of prospective billing practices. Therefore, knowing who is responsible for which functions, will greatly help getting the answers you need quickly.

If you have topics, you would like MSHBC to cover, please e-mail them to J[email protected] or [email protected].

Stay tuned for more coding and compliance articles.