Understanding Medical Billing and Coding Compliance

By Karen Smiley

In the healthcare world, rules are referred to as compliance. Compliance simply means following the rules for billing and coding as well as patient confidentiality as established by the United States Office of Inspector General. Compliance also requires that every medical provider notify patients of their rights, including access to their own records.

From a coding and billing perspective, compliance is another word for adhering to the correct coding edits — learning what may and may not be billed together and not abusing modifiers in an effort to bypass payer edits. Payers have the right to audit your records if they suspect incorrect unbundling and may flag your provider if they identify a pattern of habitual over coding. This situation will delay payment and affect your office revenue cycle.

The foundation of every claim is medical necessity, which you report with an ICD diagnosis code. Choosing the proper code makes all the difference and requires knowledge of anatomy and medical terminology. Currently, coders use ICD-9 codes; if ICD-10 implements on time (October 1, 2015), coders will report with those codes.

Coders bill numerous procedures every day. Depending upon what kind of provider you find yourself working for, you may be billing for evaluation and management encounters, surgery, pathology, or durable medical equipment. Regardless of your provider’s specialty, you need to be familiar with the particulars of coding and billing. It’s your responsibility to make sure that any code billed is fully supported by documentation. If the documentation is missing, it can’t be billed. Period. The mantra of the coder: “If it wasn’t documented, it wasn’t done.”

It’s the coder’s or biller’s responsibility to stay current with regard to payer-specific guidelines. If your provider has a contract with a commercial payer, you need to know the specifics. You also need to know whether provider enrollment is required before seeing a patient. If enrollment is required but not done, you need to refer to your office policy on patient billing.

Regardless of what the contract states, you will need to be mindful of payer policy for timely filing. Payers differ in this regard; some require claims to be submitted within 90 days of service, while others allow up to one year. Some require you to provide proof of timely filing; in those cases, you need to know what the payer requires as proof. Some require an acceptance report from your clearinghouse.

Knowing the rules will help you keep the office in check and payments flowing. Be sure to know what your provider and payer require so you can be compliant.