Medical Billing Compliance Guide Checklist

Selecting the appropriate Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code is a critical step in accurately documenting medical services. This process involves identifying the specific procedure or service provided to the patient and matching it with the correct CPT or HCPCS code from the American Medical Association's (AMA) CPT manual or the Centers for Medicare and Medicaid Services' (CMS) HCPCS manual. The selected code must accurately reflect the procedure performed, taking into account factors such as the type of procedure, the anatomical location, and any modifiers that may be required to ensure accurate reimbursement. This step ensures compliance with coding guidelines and regulations, preventing potential errors or discrepancies in billing and payment.

Insurance verification is performed to confirm the existence of valid insurance coverage for patients or customers. This process involves checking with the patient's or customer's insurance provider to ensure they have active coverage and that it covers the services or treatments being provided. The goal is to verify accurate policy information, including coverage details, premium payments, and any applicable waiting periods. This verification helps prevent billing errors, ensures compliant claims submissions, and facilitates smooth communication between healthcare providers, insurance companies, and patients/customers. By verifying insurance coverage, we can accurately determine the financial responsibilities of all parties involved, which is essential for efficient and effective service delivery.

In this step, the applicant submits their claim through our designated online portal or by mail to our office. The submission must include all required documentation and supporting evidence as specified in our guidelines. This ensures that the review process can proceed smoothly and efficiently. Once received, our team reviews the claim for completeness and accuracy before processing it further. If any additional information is needed, applicants will be notified promptly. This stage is crucial in ensuring that claims are processed correctly and in a timely manner. All submitted claims will be reviewed and verified to ensure compliance with our policies and procedures prior to payment or denial.

The ICD-10 coding process involves assigning a unique code from the International Classification of Diseases, Tenth Revision, to each clinical diagnosis or condition documented in the patient's medical record. This process enables accurate and standardized recording of diseases, injuries, and external causes of morbidity and mortality. A qualified coder reviews the diagnostic information provided by healthcare providers to determine the most appropriate ICD-10 code for each condition. The selected codes are then used to classify and report diagnoses on claims forms, electronic health records, and other documents. ICD-10 coding ensures consistency in reporting medical conditions across different healthcare settings and facilities, facilitating improved data collection, analysis, and research. Properly assigned codes also aid in the reimbursement process by enabling accurate calculation of patient charges.

The sixth step in our data management process is focused on ensuring the confidentiality, integrity, and availability of all patient health information. This step involves reviewing and implementing policies to safeguard protected health information (PHI) as governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Our team verifies that all electronic systems and storage devices used for storing or transmitting PHI meet the required security standards set forth by HIPAA's administrative, technical, and physical safeguards. We also ensure that our staff has received proper training on maintaining patient confidentiality and handling sensitive information in compliance with federal regulations. This diligence guarantees the integrity of patient data and upholds the trust placed in us as responsible custodians of this private information.

VII. OIG Exclusion Check Perform an Office of Inspector General (OIG) exclusion check on all entities to be included in the application to ensure they are not excluded from participating in federal healthcare programs due to misconduct or other factors. Utilize the OIG's List of Excluded Individuals and Entities (LEIE) database to verify the inclusion status of each entity. This verification should be conducted for both new and existing entities within the organization. Failure to conduct a thorough exclusion check may result in application denial or revocation, as well as potential liability for participating in federal healthcare programs with excluded entities.

Verify that all systems, applications, and data storage solutions comply with the applicable Centers for Medicare and Medicaid Services (CMS) regulations. This includes adherence to the Health Insurance Portability and Accountability Act (HIPAA), the Electronic Health Record (EHR) Meaningful Use guidelines, and any other relevant CMS mandates. Ensure that all system changes are reviewed and approved by the authorized representatives of the organization before implementation. Perform regular audits to confirm ongoing compliance with CMS regulations. Document all compliance efforts and maintain a record of CMS-related policies, procedures, and audit results. Develop and implement corrective action plans for any identified non-compliance issues.

Determine if the facility is located in one or more states that have specific requirements for certain types of activities, such as hazardous waste generation, storage, or disposal. If state-specific requirements apply, ensure compliance with those regulations in addition to federal regulations. This may involve obtaining any necessary permits or licenses from the relevant state agency and implementing additional safety measures or reporting requirements as required by the state. Review state laws and regulations to determine if they differ significantly from federal standards, and take steps to address these differences through facility operations and record-keeping practices.

The Compliance Review process step involves a thorough examination of all procedures, guidelines, and policies to ensure adherence to relevant laws, regulations, industry standards, and organizational policies. This review assesses whether existing practices align with established compliance requirements, identifying any gaps or deviations that may impact the organization's reputation, financial stability, or relationships with stakeholders. The Compliance Review process also considers the effectiveness of internal controls, risk management strategies, and audit procedures in preventing non-compliance incidents. It ensures that all relevant documentation, including contracts, agreements, and reports, is accurate, up-to-date, and compliant with regulatory requirements.