Mistakes in medical coding and billing, results in monetary loss to the healthcare practitioners. Year on Year OIG (Office of Inspector General) and CMS (Centers for Medicare & Medicaid Services) rules and regulations are proving to be difficult to comply with, so non compliance to these rules can prove to be fatal, thus it has become more important to know techniques for proper documentation to improve compliance and minimize audit risks. Investing sufficient time and resources in ensuring correct and proper coding will save healthcare professionals from paying penalties associated with inappropriate coding and billing.
The Medicare Fee-for-Service improper payment rate fell from 9.51 percent in 2017 to 8.12 percent in 2018, but insufficient documentation continues to be a problem.
In today’s highly regulated environment, there are multitudes of compliance risk areas that providers need to prepare for. Both the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) Office of Inspector General (OIG) have emphasized the importance of conducting risk assessments and thus establishing effective internal controls for compliance.
In order to avoid the above listed penalties here are some steps that one can follow for proper documentation, that will ensure correct coding and improve compliance:
- To understand the complexities of what has changed, coding staff should be given timely training to ensure accuracy of coding is maintained.
- In order to identify areas of additional education and support to coding staff, internal audits should be conducted periodically, so as to ensure inconsistencies in coding are minimized and timely action can be taken to improve the disparities.
- To effectively deal with a coding issue organizations should have updated coding references accessible both online as well as in the form of hard copy.
- To authenticate medical codes, physicians should be provided with detailed information, so as to ensure that they are well aware of new changes.
- Staying up to date with the trending coding practices, will minimize the risk of penalty.
Improper documentation and non compliance not only effects financially but also destroys your relationship with clients. Medical billing and coding is a difficult process which consumes a lot of time and a little mistakes can prove to be fatal, so in order to avoid penalty and save time, you can also outsource billing, coding and documentation to agencies, as Safe Professional practice will simplify the process which in turn increases accuracy.