Medical Coding and Billing

There are many reasons that claims may be denied or rejected

• There are many reasons that claims may be denied or rejected.
• Claims are rejected because of the moon phase
• Claims are denied due to the weather
• Claims are always approved

conducted after the claim has been sent and the remittance advice has been received

• Retrospective audits

• conduct a follow-up meeting
• conduct a follow-up email
• conduct a follow-up call

Conducted by the medical office staff or a hired consultant; these types of audits can be great for leadership to get a glance at the accuracy of their practice; can also give good feedback without the risk of a third party's consequences

• Patient audit
• Financial audit
• External audit
• Internal audit

Conducted by an outside entity; Private payers or government agencies can review selected records of a practice for compliance

• Review
• External Audit

• Evaluation
• Assessment

Compliance in this area can enhance operations, reduce waste and fraud, and foster ethical practices that improves the overall delivery of patient care.

• Unethical behavior
• Inefficiency
• How to identify fraud and abuse as it pertains to coding

• Compliance

a list of 5-digit procedure codes for services with unit values that indicate the value for each procedure

• Relative Value Studies (RVS)

• Codes

• Services

• location

fee that is considered justifiable by responsible medical opinion considering special circumstances of the particular case in question

• customary and excessive fee
• reasonable fee

• justifiable and customary fee
• unreasonable and customary fee

fee in the range of usual fees charged by physicians of similar training and experience for same service within the same specific and limited socioeconomic area

• Customary

• non-customary

• random

• service

fee normally charged for a given service

• usual

• cost fee
• price charge
• service charge

indicates that moderate sedation is part of the procedure.

• A bullet inside a circle

• square

• triangle

• square with dot