Coding Assignment
Assignment:
This week you will complete a 5-part coding essay. Insure your essay is in APA format. Use a Level 1 heading to separate your sections (Page 62 of the APA Publication Manual). This paper should be 4-5 pages. Insure information is referenced and cited.
Address the following points:
- Explain how to prevent coding errors
- What should you do if you catch or see a coding error?
- Explain the different types of audits and when they would be used
- Explain medical necessity and provide an example
- Go to www.fbi.gov. At the top of the webpage in the search box type in: Healthcare Fraud. Locate one healthcare fraud case and summarize the case including finding and sentencing. Then identify what went wrong and what the healthcare professional could have done differently to prevent this lawsuit.
Assignment Expectations:
- Length:
- answers must thoroughly address each question in a clear, concise manner; 1000 words (about 4 pages)
- Structure:
- title or reference page required
- address each question using level headings
- References:
- Are required and need to be cited in the submission
- Format:
- save your assignment as a Microsoft Word (.doc or .docx), Open Office (.odt) or rich text format (.rtf) file type
- File name:
- name your saved file according to your last name, first initial and the week (for example, “jonesb.week1”)
- Submission:
- submit your assignment to the Drop Box
SAMPLE COMPLETED ASSIGNMENT
Coding and Types of Audits
Coding errors in billing in healthcare facilities can lead to fraudulent or inaccurate billing, which might seriously impact healthcare providers, patients, and payers. Healthcare professionals should ensure that they resolve all coding errors to improve the quality and safety of services provided. Coding errors should also be resolved to prevent hospitals from losing money in form of fines and penalties. The purpose of this assignment is to provide ways to prevent coding errors, resolve errors that occur, and discuss types of audits.
Preventing Coding Errors
Healthcare facilities have the responsibility to prevent coding errors promote ethics in billing, avoid regulatory or legal penalties, and improve timely and accurate reimbursement. The following are ways healthcare providers can prevent coding errors in billing. One of the ways is by training billers and coders (Markovitz et al., 2019). Healthcare facilities management should ensure that their billers and coders are well-trained and knowledgeable about the latest billing and coding regulations and guidelines. Regular updates and training sessions can help billers and coders stay up-to-date on any billing regulation change. The second way is using coding software. Coding software can reduce coding errors by automating the process. The third way is double-checking the codes before confirming the claim.
The billers and coders should confirm that the codes are right before submitting them. Fourth, healthcare facilities can prevent coding errors by conducting regular audits (Markovitz et al., 2019). Regular audits can help identify errors in coding and ensure adherence to billing and coding guidelines. After audits, corrective actions should be taken to resolve the coding errors. Fifth, the coders, and billers should ensure that they communicate with providers to ensure that the right codes are documented. Clear documentation can help prevent errors in coding and improve the payment of services. Lastly, healthcare providers should ensure that they are up-to-date with any changes in coding regulations and guidelines.
What to do if Coding Error is Detected
If a coder or biller catches a coding error during billing, it is vital to take immediate action to prevent legal cases. One of the things the coder or biller can detects an error is document it. An error should be documented if it is detected. The details of the incorrect code and the right code that should have been used should be recorded. The coding error should be recorded for easy tracking, investigation, and correction (Markovitz et al., 2019). The second step is notifying the appropriate people. Once, a nurse identifies a coding error, he or she will notify the appropriate parties including the billing department, the biller or coder responsible for the error, and the provider.
Notifying appropriate people can help prevent the error from occurring again in the future and ensure that the proper code is used for reimbursement. After notifying the appropriate parties, the error should be corrected. The healthcare provider should work with the coder or biller to correct the code to avoid denials or delays in reimbursement. The healthcare provider should ensure that the right code is used to claim payment (Markovitz et al., 2019). A root cause analysis should also be conducted to identify the cause of the error and how it should be avoided. Lastly, the claim should be monitored to ensure that it is correctly processed and proper reimbursement is received.
Types of Audits
There are various types of audits that are used for different purposes. The first type of audit is a financial audit. The audit is used to examine the financial records of a healthcare facility to ensure that they are complete, accurate, and comply with regulations and accounting principles. The second type of audit is a billing audit (Hut-Mossel et al., 2021). This type of audit focuses on the facility’s invoicing and billing practices. It examines the accuracy of the bills, invoicing processes, and whether it adheres to relevant regulations and laws. Coding and charges are also reviewed in this audit. This type of audit is used to handle complaints appeals and denials. The third audit is an operational audit. It is used to evaluate the internal procedures and processes of a company and areas that can be improved.
This audit is used to ensure that the facility is operating effectively and efficiently (Hut-Mossel et al., 2021). The fourth type of audit is a compliance audit. This type of audit is used to evaluate the company and whether it complies with relevant laws and regulations guiding its operations. Another type of audit is an information technology (IT) audit. IT audit evaluates the facility’s IT infrastructure and controls. The last type of audit is a clinical audit. A clinical audit examines whether the healthcare facility provides safe and quality care to its patients (Hut-Mossel et al., 2021). The hospital’s clinical outcomes are compared to established guidelines and standards.
Medical Necessity
Medical necessity is defined as a requirement that healthcare procedures and services be deemed and justified as necessary for the treatment or diagnosis of an injury or illness (Ngaage et al., 2019). A medical necessity is determined by the medical condition of a patient and accepted guidelines and standards of healthcare practice. Medical necessity is a key factor in determining payment for healthcare services by private and government insurance payers.
Healthcare procedures and services that are considered medical necessities are typically covered by insurance plans and those that are not deemed a necessity may need additional justification for insurance payment or may not be covered (Ngaage et al., 2019). Medical necessities are determined by considering the symptoms, medical history, and overall status of the patient, as well as best practices and appropriate clinical guidelines for treatment and diagnosis. Healthcare professionals determine medical necessities using established guidelines by private and government payers, such as Medicaid or Medicare, as well as medical societies and professional organizations.
An example of a medical necessity is a patient who comes to the clinic with complaints of shortness of breath and chest pain, which may point toward a heart attack. A physician might order a series of tests including blood tests, an electrocardiogram (ECG), and a chest x-ray to make an informed diagnosis of the case. These tests can be considered medical necessities because they are needed to make a diagnosis and treat a life-threatening illness. Another necessity, in this case, is treatment. For instance, a cardiac catheterization procedure might be considered if the patient has a heart attack to restore blood flow to the heart.
Healthcare Fraud Case
An urogynecologist from West Michigan was found guilty of adulteration of medical devices and healthcare found in 2021 a sentenced to 108 months in prison (US Department of Justice, 2020). The physical was found guilty of submitting false claims to private insurance companies and Medicare for medical devices that the patients did not use. According to the US Department of Justice (2020), investigations found that the physician had solved medical devices that are not FDA-approved for patients and overcharged insurance companies for FDA-approved devices. The physician used defective devices in some cases and thus risking the health and life of patients. He was also found guilty of altering the medical devices’ labels and making them appear as FDA-approved, yet they are not. In addition to the sentencing, the physician was charged $3 million.
The physician should have prevented the lawsuit by doing the following. First, he should have ensured that all his medical devices are FDA-approved and safe for patient use. He should have ensured that the medical devices sold to medical insurance companies are approved by the FDA (Al-Hashedi & Magalingam, 2021). The physical should have also conducted quality control checks to ensure that the medical devices are not expired and are in good condition. He should have also followed the coding guidelines to ensure that medical services and procedures are not overpriced (Al-Hashedi & Magalingam, 2021). Lastly, he should have also ensured all services and procedures that have been coded are provided to patients.
Conclusion
Healthcare providers have the responsibility to ensure that coding during billing is free of errors to avoid being charged with healthcare fraud and criminal cases. Coders should ensure that they follow the current guidelines and regulations on coding to ensure that they do not make any mistakes. The physician in the summarized case should have followed the set guidelines for coding medical services and procedures to avoid the lawsuit. He should have also followed the ethical practice principles when billing his patients.
References
Al-Hashedi, K. G., & Magalingam, P. (2021). Financial fraud detection applying data mining techniques: A comprehensive review from 2009 to 2019. Computer Science Review, 40, 100402. https://doi.org/10.1016/j.cosrev.2021.100402
Hut-Mossel, L., Ahaus, K., Welker, G., & Gans, R. (2021). Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. PloS One, 16(3), e0248677. https://doi.org/10.1371/journal.pone.0248677
Markovitz, A. A., Hollingsworth, J. M., Ayanian, J. Z., Norton, E. C., Moloci, N. M., Yan, P. L., & Ryan, A. M. (2019). Risk adjustment in Medicare ACO program deters coding increases but may lead ACOs to drop high-risk beneficiaries. Health Affairs, 38(2), 253-261. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05407
Ngaage, L. M., Rose, J., Pace, L., Kambouris, A. R., Rada, E. M., Kligman, M. D., & Rasko, Y. M. (2019). A review of national insurance coverage of post-bariatric upper body lift. Aesthetic Plastic Surgery, 43, 1250-1256. https://link.springer.com/article/10.1007/s00266-019-01420-7
The US Department of Justice. (2020). West Michigan urogynecologist sentenced to prison for healthcare fraud and adulteration of medical devices. https://www.justice.gov/usao-wdmi/pr/2020_1029_Beyer_Wright
Jermaine Byrant
Nicole Johnson
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