Coding Compliance

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Submitted By kitcat4412
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Coding Compliance: Practical Strategies for Success by Sue Prophet, RRA, CCS, and Cheryl Hammen, ART
"Fraud," "abuse," "upcoding," "unbundling," and "compliance" have all become buzzwords in the news media. Eliminating healthcare fraud and abuse has become a top priority for the federal government. Government investigations are on the rise and providers everywhere tremble at the thought of becoming the next investigative target. An Office of Inspector General (OIG) audit of the Health Care Financing Administration (HCFA) revealed errors in 30 percent of all claims paid by HCFA in fiscal year 1996.1 These errors account for approximately $23.2 billion annually, or 14 percent of total Medicare fee-for-service (i.e., excluding managed care) payments. About half of the errors identified resulted from insufficient or lack of documentation from providers, and one-third of the documentation errors were associated with providers who failed to respond to repeated requests from auditors to submit documentation. The breakdown of the types of errors resulting in the improper payments is as shown in Figure 1.
Breakdown by type of provider is shown in Figure 2.

Figure 1 Insufficient/No documentation 46.76%
Lack of medical necessity 36.78%
Incorrect coding 8.53%
Unallowable service 5.26%
Other 2.67%

-------------------------------------------------------------------------------- Total 100%

Figure 2
Inpatient (PPS) 22.59%
Physician 21.68%
Home health agency 15.74%
Outpatient 12.12%
Skilled nursing facility 10.45%
Laboratory 5.76%
Other 11.66%

-------------------------------------------------------------------------------- Total 100%

As a result of these audit findings, providers can expect to see increased efforts…...

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