Evaluating Compliance

Evaluating Compliance Strategies

Andria Cogar


December 20, 2009
Summer Tierno

Evaluating Compliance Strategies

    The medical billing and coding staff members working in physicians’ offices have a very complicated and onerous job preparing bills to submit for payments of services rendered. They must make sure they are using the correct and updated Current Procedural Terminology, also known as CPT codes; but also be able to provide what procedures were done and why they were preformed as well. There are times when claims that are submitted were not complete and had to be denied until further detailed information could be provided.
    There are several steps in the medical billing and coding process. In the medical billing process, after the patient encounters, physicians prepare and sign documentation of each patients visit. The next step is to post the medical codes and transactions of the patients visit in the practice management program to prepare the claims. The process used to generate claims must comply with the rules imposed by federal and state laws as well as with payer requirements. Coding specialists must be able to identify the bundling of codes; most offices go by Medicare’s lists to ensure they are clear on the procedures provided (Valerius, 2008). CPT Modifiers must be used correctly so there is no confusion with the payer. This is where there can be implications of incorrect medical coding.
    When procedures are performed, they must be consistent with the diagnosis to be sent in for payment. Payers provide offices with their own lists that they approve and provide the right ways to find codes allowed (Youngstrom, 2008). It is very important to link the diagnosis codes with the services that were provided because a patient was to receive a diagnosis of an allergic reaction to a medication but the procedure results in the patient being administered this medication, the patient could endure yet another allergic...