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When patients have medical insurance, patient account specialists must take the payer's billing requirements into account. In the inpatient setting, there are hospital charges associated with ICD-9-CM codes; in the outpatient setting, charges are related to HCPCS/CPT procedure codes. Although charges are related to all the codes reported on hospital claims, each code is not necessarily payable; payment depends on the payer's rules and the terms of the contract with the provider. Following these rules and terms when preparing claims results in billing compliance. Compliant billing avoids even a remote suggestion of fraudulent or abusive behavior and ensures the maximum appropriate reimbursement for the hospital. Learning ObjectivesDescribe the purpose and use of the Medicare Inpatient Prospective Payment System.Explain how a DRG is assigned. Compare and contrast MCC, CC, and non-CC. List the eight conditions that will not be considered for assigning a DRG unless they are documented as existing when the patient was admitted. Discuss the types of errors that are detected by the Medicare Code Editor. Describe the purpose and use of the Medicare Outpatient Prospective Payment System. Explain how an APC is assigned. List the three types of CCI edits. Discuss fraud and abuse in the hospital billing setting. Describe the parts of a compliance plan. Explain the purpose of a pay-for-performance program. |