Principles of Healthcare Reimbursement Student Workbook Chapter 2 Clinical Coding and Coding Compliance Activities Theory into Practice This chapter discusses coding and billing compliance. The first half of the chapter discusses the code sets that are utilized by providers to communicate their services and supplies to the payer. The second half of the chapter discusses how payers identify claims that were improperly submitted for payment. In the Recovery Auditing in Medicare for Fiscal Year 2013 report, the National Recovery Audit Program reports that the RACs collected 3.75 billion in improper payments. This figure has drastically increased since 2010, where the monies recovered by RACs totaled 92.3 million. Review the RAC 2013 Report to Congress located at: http://www.cms.gov/ResearchStatistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/Recovery-Audit-Program. Questions 1. Why are facilities and providers unable to prevent the improper claims that the RACs have identified in their reviews? 2. What can providers and facilities learn from this report? 3. What key points can be identified and then implemented at the coder, physician, and clinician level to improve reporting processes? Application Exercises 1. Locate the current Office of Inspector General Work Plan on the Health and Human Services Office of Inspector General website. Write a memo to your Compliance Officer outlining the key areas for your inpatient facility. Identify which areas would be appropriate for the auditing schedule, which areas would be appropriate for the education schedule, and which areas would be appropriate for both schedules. 2. Visit the Medicare CERT homepage. Locate the most recent CERT annual report. Use Appendix B: Projected Improper Payments and Type of Error by Type of Service for each Claim Type to identify the top issue for the following claim types: Part B, DMEPOS, Part A excluding Inpatient Hospital PPS and Part A Inpatient Hospital PPS. For each claim type identify the top issue (for Part A Inpatient Hospital PPS identify the top clinical area). For each top issue identify the payment implication, the error rate, and the most significant error type. After reviewing the statistics discuss what providers and facilities should do to improve their performance. 1