By Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H TOP 10 Coding and Compliance List In the spirit of David Letterman, I thought it would be fitting to start the new year with a top ten list of areas that you should consider to address so you and your clients are compliant in 2014. This article is not intended to focus on your contracts or responsibilities with your clients, but I would argue that compliant clients are easier to manage and definitely ensure that you sleep better at night. Helping your clients stay out of the audit limelight will yield financial dividends as well as long-term loyalty. The following list is a top ten countdown of some key areas of importance. One could argue over the order and the items listed, but it should provide a good representation of the types of issues that you should make time to evaluate. and now, ladies and gentleman, number ten…. NUMBER 10: CLINICAL TRIALS. effective January 1, 2014, the Centers for medicare & medicaid services (Cms) no longer considers the inclusion of the clinical trial number to be voluntary; now, health care providers are required to report the eight-digit trial number on all claims during the time period the patient participates in the trial.1 Once the clinical trial number has been captured by the Cms Common Working File (CWF), any subsequent claim for that patient without the mandatory trial number could be rejected. as a result, it is essential that internal tracking of clinical trial patients be maintained to ensure that all services (including, but not limited to, treatment, imaging, laboratory, professional charges, surgery, and other related diagnostic or therapeutic procedures) include the appropriate clinical trial number to prevent claim rejection. In addition, all physicians and facilities providing any part of the trial patient’s care must coordinate to appropriately report investigational and routine services performed as part of the trial protocol. NUMBER 9: PHYSICIAN SUPERVISION. Physician supervision is an ongoing area of concern. as a general rule, there is no passive income for physicians. They have to be actively performing a service or providing the appropriate level of supervision to bill for services. Incident-to services are addressed later in the list as a separate 34 HBma BILLINg • JaNuaRY.FeBRuaRY.2014 issue. Cms requires physician supervision of diagnostic imaging exams and other diagnostic tests. The required supervision can be provided only by a physician, not by a non-physician practitioner. There are different levels of supervision, and you can find out which level is required for a specific exam by looking up the procedure code on the Cms website using the Physician Fee schedule (PFs) search feature.2 The appropriate level of supervision must be performed and documented to ensure that it is clear, in the patient’s record, and on the claim who provided which service. NUMBER 8: MEDICAL NECESSITY.medical necessity will continue to be an overarching area of concern for all types of medical services. Just because a physician provides a service, it does not automatically mean that the payor will consider it medically necessary for that patient’s condition. It is important that the provider take reasonable measures to ensure that only claims for services that are reasonable and necessary, given the patient’s condition, are billed. Documentation must support the determinations of medical necessity when physicians order tests or services believed to be appropriate for the treatment of the patient, and advance Beneficiary Notices of Noncoverage (aBNs) are used when there is a likelihood that an ordered service will not be paid. Regardless of how it is defined, medical necessity is a key to reimbursement, and health plans continue to have difficulty allowing reimbursement for services deemed to be experimental or investigational in nature. NUMBER 7: PERFORMING PROVIDER. Like the other issues, this is also not a new area of concern. The question is: what do you do when the group hires a new physician who is not yet credentialed with medicare or the required commercial payors? The answer must consistently be that you bill according to the payor’s requirements even if it means that the organization does not receive payment for the provided services. It is not appropriate to “get creative” or do anything less than complete compliance to ensure correct billing practices. Remember, new physicians are not locum tenens. NUMBER 6:MODIFIER 59.modifier 59 is arguably the most useful,
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