CodeBusters : A Quick Guide to Coding and Billing Compliance for Medical Practices

by Aalseth, Patricia T.

• ISBN13: 9780834213173
• ISBN10: 0834213176
• Format: Paperback
• Copyright: 1998-12-01
• Publisher: Jones & Bartlett

Summary

With healthcare costs continuing to skyrocket, despite the efforts of managed care and other containment programs, third-party payers are scrutinizing every line of every claim for services. When questionable items are identified, the next step is usually a request for copies of your patient's medical records, in order to verify that services billed were actually provided. As a physician, whether in a large group or solo practice, you must understand how the coding and billing process works, and assure that all official guidelines are being followed by your staff. This book is a quick reference to the basics of coding for physician services, and provides checklists of questions for physicians and office staff. Also included are suggested resources for additional assistance with coding and billing problems.

Table of Contents

Preface	v
What Are the Rules?	1	(4)
Provider responsibility for accuracy of coding
Official coding guidelines for physician services
Diagnosis coding
Procedure coding
Coding rules for non-HCFA payers
Why you need written policies and procedures
Patient Records---The Basis of Coding	5	(5)
Improving the record
Organization/format
Forms
Improving the documentation
Content
Legibility
Other improvements
Translating the Record into Codes---Diagnosis	10	(5)
Primary diagnosis
Rule/out
V codes
Payable diagnoses
Cheat sheets/superbills
Diagnoses for procedures
Translating the Record into Codes---Procedures	15	(5)
Nonbillable procedures
Bundled procedures
Global package
Modifiers
Translating the Record into Codes---Evaluation and Management	20	(10)
Definitions
Counseling and coordination of care
Newborns/critical care/discharge day
Prolonged services/preventive medicine/care oversight
Decision-making documentation
Audit tool for E&M services
What Went Wrong?	30	(4)
Clean claims
Payment denials
Prior approvals
How to appeal denials
Resources for You and Your Staff	34	(4)
Training/credentialing
References/software
Payer newsletters and manuals
Internet resources
Consultants
Professional organizations
Appendix A. Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office)	38	(3)
Appendix B. Data Elements for Adequate Documentation	41	(7)
Appendix C. Bibliography	48