Podcast
Questions and Answers
What is the consequence of inadequate documentation in claims submission?
What is the consequence of inadequate documentation in claims submission?
- The claim will automatically be approved.
- Providers will receive an increased payment.
- Claims may be denied as services are considered not performed. (correct)
- The documentation will be requested after payment is received.
Which approach should coders take to avoid denials related to documentation?
Which approach should coders take to avoid denials related to documentation?
- Only address coding issues as they arise reactively.
- Minimally check documentation only after denials occur.
- Adopt a proactive approach to identify process deficiencies. (correct)
- Wait for the billing errors to surface during auditing.
Which of the following is a felony under U.S.C. § 1347?
Which of the following is a felony under U.S.C. § 1347?
- Failing to document services provided.
- Responding late to a review of billing practices.
- Accidentally submitting incorrect claims.
- Knowingly defrauding a health benefit program. (correct)
What should practices have in place to mitigate risk during audits?
What should practices have in place to mitigate risk during audits?
How are duplicate bills typically classified in claims processing systems?
How are duplicate bills typically classified in claims processing systems?
What is the risk of resubmitting a claim instead of properly following up on it?
What is the risk of resubmitting a claim instead of properly following up on it?
What differentiates coding accuracy from insufficient documentation?
What differentiates coding accuracy from insufficient documentation?
What could be a potential consequence of a practice's failure to understand healthcare fraud regulations?
What could be a potential consequence of a practice's failure to understand healthcare fraud regulations?
What is the filing deadline for Medicare fee-for-service claims for services furnished on or after January 1, 2010?
What is the filing deadline for Medicare fee-for-service claims for services furnished on or after January 1, 2010?
For institutional claims that include span dates of service, which date is used to determine timely filing?
For institutional claims that include span dates of service, which date is used to determine timely filing?
When submitting professional claims with span dates of service, which date is considered for timely filing?
When submitting professional claims with span dates of service, which date is considered for timely filing?
What could happen if the line item 'From' date is not timely while the 'To' date is timely?
What could happen if the line item 'From' date is not timely while the 'To' date is timely?
Which of the following is NOT a common error that can lead to claim denial?
Which of the following is NOT a common error that can lead to claim denial?
What should be checked to avoid errors related to patient identifiers?
What should be checked to avoid errors related to patient identifiers?
Which coding system is NOT referenced as potentially leading to claim denial if outdated?
Which coding system is NOT referenced as potentially leading to claim denial if outdated?
What is one important factor to verify when working with multiple insurance policies?
What is one important factor to verify when working with multiple insurance policies?
Which of the following identifiers must be identical for exact duplicate claims?
Which of the following identifiers must be identical for exact duplicate claims?
What is the consequence of upcoding in the healthcare billing process?
What is the consequence of upcoding in the healthcare billing process?
Which method is considered illegal when billing for medical services?
Which method is considered illegal when billing for medical services?
What is the purpose of using modifiers in medical billing?
What is the purpose of using modifiers in medical billing?
What may be required by a payer before adjudicating a claim?
What may be required by a payer before adjudicating a claim?
Which terminology describes the submission of tests or procedures that are meant to be billed as one service?
Which terminology describes the submission of tests or procedures that are meant to be billed as one service?
What is an affective practice to ensure coding accuracy?
What is an affective practice to ensure coding accuracy?
Which of these practices contributes to timely filing requirements?
Which of these practices contributes to timely filing requirements?
Study Notes
Insufficient Documentation
- Imperative to bill only what is documented
- Lack of documentation may lead to denial of claims
- Providers need to be active in improving documentation practices
Billing Fraud
- Intentionally defrauding any health benefit program is a felony
- It is illegal to knowingly make false statements to receive healthcare payments
- Lack of knowledge is not a defense against fraud charges
Duplicate Billing
- Duplicate bills might arise from human error, resubmitting claims, or not removing canceled procedures from patient accounts
- Systems evaluate claims for potential duplication
- Claims are categorized as exact duplicates or suspect duplicates
- Timely filing guidelines vary between commercial and Medicare providers
Medicare Timely Filing
- Medicare fee-for-service claims must be filed within one calendar year from the date of service
- Claims filed beyond the deadline will be denied or rejected
- For claims with span dates of service, the "Through" date determines the date of service for timely filing
- For professional claims, the line item "From" date determines the date of service for timely filing
- If the "From" date is not timely but the "To" date is timely, Medicare contractors will process the timely portion of the claim separately
Incorrect Patient Identifier Information
- Verify the accuracy of patient information on claims including name, date of birth, sex, insurance payer, and policy number
- Ensure the presence of required group numbers and accurate patient relationship to the insured
- Confirm the accuracy of diagnosis codes matching the procedure performed
- Properly indicate the primary insurance in case of multiple insurances
Coding Issues
- Using outdated coding books can result in denial of claims and revenue loss
- Utilize updated CPT, ICD-10, and HCPCS codebooks
- Superbills should be reviewed regularly for accuracy
- Claims may appear as duplicates due to the nature of the service
- Proper coding with applicable condition codes or modifiers will identify the claim as a separate service
- Exact duplicate claims will contain matching information including HIC number, provider number, date of service, procedure code, place of service, and billed amount
Upcoding or Unbundling
- Upcoding refers to using a higher-paying code on a claim for higher reimbursement or billing for a covered service in place of a non-covered service
- Unbundling involves submitting bills for separate components of a service instead of billing them together
- Both practices are illegal and considered fraudulent
- Unbundling may seem profitable but is a violation of Medicare's package of care reimbursement model for surgeries
- Understanding the usage of modifiers and their role in coding is crucial in avoiding fraud
Further Documentation Requested
- Payers may require medical records before adjudicating a claim
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