Week 3 Discussion
1) Discuss some common causes for coding errors and the preventative measures you can use to avoid them.
2) What are some other measures you can add to the list that might not be in the course materials?
3) What is the Fraud and Abuse Control Program? What is the HHS OIG and what is it’s major concern? (Be sure to watch the video below.)
A Roadmap for New Physicians: Avoiding Medicare and Medicaid Fraud and Abuse
The video summarizes the five main Federal fraud and abuse laws (the False Claims Act, the Anti-Kickback Statute, the Stark Law, the Exclusion Statute, and the Civil Monetary Penalties Law) and provide tips on how physicians should comply with these laws in their relationships with payers (e.g., the Medicare and Medicaid programs), vendors (e.g., drug, biologic, and medical device companies), and fellow providers (e.g., hospitals, nursing homes, and physician colleagues).
Please review the discussion board rubric found under “Start Here”.
Use in-text citations appropriately and provide full citations for your initial post and at least one of your response posts. One of your citations needs to be outside of your text.
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discussion week 3
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These are some of the most common causes for coding errors:
Unbundling of services
Billing for medically unnecessary services
Billing for services not covered under health plan
What are some other measures you can add to the list that might not be in the course materials?
Reviewing to assure there is no incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)
Assuring insurance provider information is accurate (policy numbers, address, contact information, etc.)
Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes
Entering too few or too many digits for ICD-9-CM codes
Inputting mismatched treatment and diagnostic codes
Forgetting to input codes at all for services performed by a physician or another healthcare official
Not having access to EOBs on denied claims
Not verifying a patient’s insurance coverage
What is the Fraud and Abuse Control Program? What is the HHS OIG and what is it’s main concern?
HHS is a Fraud and Abuse Control Program
OIG carries out nationwide audits and investigations. They have the authority to investigate basically any healthcare facility.
There primarily concern is to make sure business comply with principles of business practice and avoid healthcare providers committing fraud.
Aalseth, P. Second Edition Medical Coding 2015
week 3 discussion
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Hospitals, physicians, and medical clinics depend on medical coding and billing to generate their income. Therefore, the coding specialists are the principal means of communication between medical providers and the insurance companies (Venezian, 1985). When errors are recorded during coding, claims may be uncompensated for, or a hospital may be forced to refile an application(s) before payment is initiated.
Causes of Coding Errors
Incorrect Medical Diagnosis
Incorrect medical diagnosis occurs when a code that is not compatible with a procedure is recorded. The error mainly ensues when there is a failure by the specialists to offer a diagnosis to the highest level or when there is an omission of the 4th or 5th digit during data entry (Venezian, 1985).
Error in the Medical Documentation
It occurs when there is a misunderstanding of the medical records and documents. Alternatively, this may happen when there is a missing billable procedure or the details required for billing.
Failure to Code to the Highest Level
The coding expert must encrypt a medical event or process to its highest degree of specificity, which requires abstraction of information from the medical reports and taking of accurate notes. Moreover, the professional should understand both the testing and diagnosis procedure of the ailment to be coded.
Strategies to Avoid Coding Errors
The most preeminent tactic that can be espoused by firms to impede errors is ensuring that the coding personnel is current on coding changes (Venezian, 1985). To achieve this, updated encryption manuals, publications, and organizing refresher training sessions for the staff members have to be provided. Moreover, the employees should be diligent since the coding job is detail-oriented and requires a thorough analysis of data presented. The errors can also be avoided by double checking the work upon completion to eliminate careless mistakes and possible omissions. Additionally, it is vital to ensure that there is communication between the coders, health professionals, and the insurance providers to facilitate clarification of ambiguous medical reports before coding is commenced. Finally, the coders should avoid the use of truncated codes; they should present the patient’s diagnosis to the highest level of specificity (Venezian, 1985).
Other Approaches for Preventing Coding Errors
Apart from the above-highlighted measures of avoiding coding errors, the following methods can also be used to minimize the risks of inaccurate coding:
Follow up on claims. It is possible for an individual to avoid and anticipate errors by following up on the previous claims filed with the insurance company (Venezian, 1985). A representative from the insurer may help to single out an error, hence providing an opportunity to resubmit an application before it is processed and denied. Secondly, coders should read the entire progress reports rather than just skim through the header to capture diagnostic information and the nature of services provided. Though the header may summarize the procedure conducted, the treatment may change as the physician gathers more information about the patient during a diagnosis (Venezian, 1985).
Fraud and Abuse Control Programs
Health Care Fraud and Abuse Control Programs are a stratagem that conceived to combat scams in health care by monitoring the delivery of services, medicals supplies, and equipment across the local, state, and federal governments (Wood, 2015). The program is directed by both the Attorney General and the Office of Inspector General, OIG. These departments are responsible for submitting annual progress reports to the Congress. HHS OIG is an acronym that is used to refer to the Office of Inspector General Department of Health and Human Services (Wood, 2015). This department is charged with the responsibility of identifying fraud and abuse of resources in Human Health Services, HHS, which harbors more than 300 health and safety programs. The main aim of HHS-OIG is to protect the beneficiaries of these programs while maintaining the integrity and delivery of health services (Wood, 2015). The program also indicts individuals who breach the law on federal insurance or embezzle health care funds.
Venezian, E. C. (1985). Coding errors and classification refinement. The Journal of Risk and Insurance, 52(4), 734. doi:10.2307/252318
Wood, C. (ed.). (2015). The Health Care Fraud and Abuse Control Program: Issues, assessments and effectiveness. New York, NY: Nova Science , Inc.