decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Fraud and Abuse / Coding and billing
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Article Overview
This article explains major coding and billing compliance risks identified by the OIG and related federal health care oversight sources. It is intended for practices, coders, billers, compliance staff, and physicians who need a broad understanding of risk areas, documentation-based billing expectations, and the role of coding standards and guidelines in compliance programs. The discussion covers common billing problem categories, the importance of aligning claims with medical record documentation, and the general use of official coding guidance across payers and specialties.
Why This Topic Matters
Coding and billing errors can trigger audits, repayment demands, and potential civil, administrative, or criminal exposure. Understanding the major risk areas helps practices strengthen compliance programs and reduce erroneous or potentially fraudulent claims.
Article Sections
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Billing and coding risk areas identified by OIG
This section outlines common compliance risk categories associated with billing and coding practices. It presents the broad types of issues that frequently appear in investigations and audits.
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Standards, documentation, and coding guidance
This section discusses how practices should align internal standards with reimbursement principles, payer requirements, and official coding guidance. It also addresses the role of documentation and claim review processes in coding and billing compliance.
What You Will Learn
- The major categories of coding and billing compliance risk discussed by OIG
- Why documentation is central to compliant claim submission
- How coding and billing standards relate to broader payer and regulatory requirements
- Which organizations issue official coding guidance
- Why review of rejected claims can support error reduction
Who Should Read This
- Physicians
- Medical coders
- Medical billers
- Compliance officers
- Practice managers
- Healthcare administrators
Modifiers Discussed
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