CPC Requirements Compliance and Regulatory Already Passed

CPC Requirements Compliance and Regulatory Already Passed POS Place of Service Inpatient POS 21 Outpatient POS 22 MPFS Medicare Physician Fee Schedule Pharmacy 01 Prison/Correction Facility 09 Physician's Office 11 Home 12 Assisted Living Facility 13 Group Home 14 Walk-In Retail Health Clinic 17 Off Campus - Outpatient Hospital 19 Urgent Care Facility 20 Emergency Room 23 ASC (Ambulatory Surgical Center) 24 Skilled Nursing Facility 31 Nursing Facility 32 Hospice 34 Independent Laboratory 81 Medical Coding fraud is financial losses estimated to range between $70 to $240 billion per year. Intentionally submitting incorrect coding and billing information is fraudulent and punishable by fines. True Double billing Submitting a single code multiple times when the procedure was only performed once. Upcoding When a code has a higher reimbursement rate is submitted, when a lesser code is more appropriate. Downcoding Assigning the patient with a lesser diagnosis and shows fake patient improvement, allowing for extended hospital stays that would not be granted otherwise. Unbundling Using single codes to encompass multiple procedures, when entire procedure is covered by one code. 1986 False Claim Act (FCA) Those charged with fraud may be assessed fines of $5,000.00 to $11,000.00 per claim. NCCI National Correct Coding Initiative Edits NCCI promotes correct coding methodologies and control improper coding for inappropriate payments in Part B claims AMA American Medical Association NCCI contains one table for Physician/Practitioners and one for Outpatient Hospital services CCI and MUEs tables are combined into one table and include PTP code pairs that should not be reported together. PTP Procedure to Procedure MUE Mutually Unlikely Edits NCCI MUE program prevents improper payment when services are reported with incorrect units of service/ What are MUE's? Maximum number of units allowed under most circumstances for a single HCPCS/CPT code on same DOS. ABN's cannot be used to seek payments for MUE's NCCI are updated Quarterly NCCI is compromised of what two provider -type choices of PTP? PTP Edits-Practitioners and PTP Edits NCCI is comprised of 3 Provider-type choices of MUEs Practitioners MUEs; Durable Medical Equipment (DME), and Facility Outpatient PTP Edits Practitioners submitted by physicians, non-physician practitioners, and ASCs (Ambulatory Surgery Centers) PTP Edits Hospital Hospital hospitals, Skilled Nursing Facilities (SNF), Home Health Agencies (HHA) Outpatient Physical Therapy (OPT), Speech Language Pathology Providers, and Comprehensive Outpatient Rehabilitation Facilities (CORF) Practitioners MUEs All physicians and other practitioner claims are subject to these edits DMEs MUEs These edits are applied to claims submitted to DME MACs. Facility Outpatient MUEs See UB-04 TOB POS