Avoid payer denials by ensuring your provider or supplier follows the rules for allowable MUE units. Understanding why Medically Unlikely Edits (MUEs) were established, how they are organized, and the criteria on which edit rationales are based may help medical coders and billers avoid denials or, at a minimum, properly resolve a denial. What Are […]
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Laureen shows you her proprietary “Bubbling and Highlighting Technique”
Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page 2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers Click here for more sample CPC practice exam questions and answers with full rationaleTag Archives: Over
Providence Health Sued Over Alleged $188 Million Medicare Upcoding Scheme
Providence Health and Services has been hit with a lawsuit alleging the health system violated the False Claims Act by purposely upcoding Medicare to increase reimbursement.
The lawsuit, filed late last week in the U.S. District Court of Central California by data analysis firm Integra Med Analytics, claims Providence, with the help of an outside consultant, pushed physicians to add secondary diagnoses when documenting treatment so the health system could qualify for higher Medicare reimbursement. The outside consultant, a clinical documentation improvement company called J.A. Thomas and Associates, also allegedly encouraged Providence’s clinical documentation integrity specialists to encourage physicians to add secondary diagnosis to patient documents. Physicians allegedly received a kickback if they complied with the requests.
Hospitals use diagnosis related groups, or DRGs, to bill Medicare. Hospitals add severity levels to the diagnosis — called a secondary diagnosis — that further demonstrate the patient’s condition. Adding severity levels that indicate complications or comorbidities can increase the reimbursement for a claim as high as $ 25,000. The suit alleges Providence fraudulently upcoded Medicare for $ 188.1 million in claims over seven years.
A Providence spokeswoman said the system received a partial version of the complaint this week and that the federal government has not intervened in the litigation.
“We reiterate that Providence St. Joseph Health follows rigorous standards for Medicare reimbursement claims, based on all relevant regulation and supported by our core values,” she added.
Providence operates 50 hospitals across five states. According to the suit, about $ 6.2 billion of Providence’s $ 14.4 billion in revenue in 2015 came from Medicare reimbursement.
An analysis by Integra using CMS claims data from 2011 to 2017 found Providence hospitals were more likely to add secondary diagnoses to claims than other hospitals. For example, the suit said Providence reported more than 11,000 claims for femoral neck fracture, of which 12% of those claims had an accompanying secondary complication for encephalopathy, which indicates brain disease. For the other hospitals, which included 1.1 million femoral fracture claims, just 4.5% reported encephalopathy. Eighteen of the 250 hospitals with the highest rates of encephalopathy were Providence hospitals, the suit said based on Integra’s analysis.
The three secondary diagnoses Providence allegedly most frequently coded for were encephalopathy, respiratory failure and malnutrition.
Additionally, St. Joseph Health, which merged with Providence in 2016, saw a jump in secondary diagnoses after it merged with Providence, according to the suit.
The post Providence Health Sued Over Alleged $ 188 Million Medicare Upcoding Scheme appeared first on The Coding Network.
Is the fight over? AORN to change recommendations in surgical headwear debate
One of the fiercest fights in surgery is about ears. Do you cover them while conducting surgery? This simple question has fueled a bitter fight ever since The Association of periOperative Registered Nurses (AORN) officially recommended that bouffant hats be worn in the OR by all surgical team members. Since then, there’s been a back-and-forth of testy statements and unsatisfying studies.
Georgia Emergency Physicians Sue Anthem Over ER Policy
The MAG (Medical Association of Georgia), alongside the American College of Emergency Physicians, sued Anthem for payment denial of some emergency department services.
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Over Coding Issue
I’ve recently started a new position with a family planning clinic and I’m the first coder they’ve ever had. The previous billing supervisor, who is no longer with the company, put a rule in place that all procedures should be billed with an E/M code & modifier 25. As we all know E/Ms shouldn’t be billed with surgical services unless there is a separately identifiable reason. This rule has been in place for approximately 2 years and our predicament is what to do about the over-payment from the insurance companies. Has anyone run into this in the past? How did your organization handle it? Thank you for any input!
Obtaining Diagnosis Over the Phone
2) Provider orders laboratory work on a patient but does not provide a diagnosis on the lab order. Can the lab staff phone the provider for a verbal diagnosis if the claim has not yet been processed for adjudication? Is the lab required to obtain a written confirmation of the diagnosis obtained via the phone call or can the lab merely document the additional info/diagnosis onto the patients lab request?
CPC with over 12 years of experience, seeking full-time, Remote Profee role
Over Ten Years Experience in Surgical and Professional Fee Certified Coder
3888 Lone Oak Rd SE
Salem, OR 97302
Phone: (503) 999-1895
[email protected]
Certifications
Chemeketa Community College:
Medical Coding and Billing Certificate
6/11 Deans List
Health Information Tech. Certificate
6/11 Deans List
Western Oregon University:
Bachelors of Science in Health
Education 2001
Relevant Course:
ICD-10 CM Coding/Reimbursement
CPT-IV Coding/Reimbursement
Advanced CPT- IV Coding
Advanced ICD-10-CM Coding
Medical Terminology
Human Diseases
Health Information Systems
Medical Insurance Billing
Medical Law and Ethics
Selected Accomplishment:
Selected to be a consultant for the ICD-10 change over for October 1, 2015
Medical coding/billing SPECIALIST
Multi-Educated Professional seeking employment in a Remote Medical Office Setting Part-Time
PROFILE
Accomplished, well-rounded coding/billing professional seeking an employment position in Healthcare remote office setting. Self-motivated, innovative, and hard-working individual. Dependable, with a genuine interest for medical coding.
Software:
EPIC, NextGen, Optum, Meditech, Epremis, TruCode, SuperCoder, Healthland, GE Centricity, MS Office (Word, Excel, Outlook, Access, PowerPoint)
Diagnostic Imaging 2016 to present
Medical Coder
Assigned ICD 10, CPT, and HCPC codes to all billable visits (Interventional and Diagnostic Imaging)
Trained and mentored prospective coders to the radiology practice.
Reviewed clinical documentation for completeness and billable to insurance.
Assisted the accounts receivable with claim denials and CCI edits.
Communicated and educated the providers regarding coding rules and documentation issues.
Hope Orthopedics 2014-2016
Coding Specialist
Assigned ICD 10, CPT, and HCPC codes to all billable visits (office visits, ED visits, consults, outpatient procedures, etc.)
Reviewed clinical documentation for completeness and billable to insurance.
Assisted the accounts receivable with claim denials and CCI edits.
Communicated and educated the providers regarding coding rules and documentation issues.
In-house consultant for the orthopedic group for the ICD-10 change-over
Samaritan Health Services 2011-2014
Charge Master HIM Coder/Analyst (CDM)
Monitor unbilled accounts and report for outstanding and/or un-coded discharges to reduce AR days.
Abstracts pertinent information from patient records for coding/billing purposes.
Liaison between Application Coordinators and Medical Records for charge issue database.
Verify requested charge issues, CPT codes, and patient information before submitting to processing.
Assist in all set up and changes to pricing and procedure code tables.
~ Positive Attitude ~ ~ Detail Oriented ~ ~ Organized ~ ~ Problem Solver ~
Pakistani transcriber threatens UCSF over back pay
A woman in Pakistan doing cut-rate clerical work for UCSF Medical Center threatened to post patients’ confidential files on the Internet unless she was paid more money. To show she was serious, the woman sent UCSF an e-mail earlier this month with actual patients’ records attached.
Click here for the full story!
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Data breach may have affected over 500,000 patients
LifeBridge Health in Baltimore notified more than 500K patients last week. They were informed that their personal information may have been compromised during a security breach in 2016 (around September). Becker’s Hospital Review was told on May 23rd that on March 18th, malware was discovered on the server that hosts ePHI data for the affiliated physician’s group and the registration and billing systems.
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