CPC Requirements Compliance and Regulatory Already Passed

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CPC Requirements Compliance and Regulatory Already Passed POS ✔✔Place of Service Inpatient POS ✔✔21 Outpatient POS ✔✔22 MPFS ✔✔Medicare Physician Fee Schedule Pharmacy ✔✔01 Prison/Correction Facility ✔✔09 Physician's Office ✔✔11 Home ✔✔12 Assisted Living Facility ✔✔13 Group Home ✔✔14 Walk-In Retail Health Clinic ✔✔17 Off Campus - Outpatient Hospital ✔✔19 Urgent Care Facility ✔✔20 Emergency Room ✔✔23 ASC (Ambulatory Surgical Center) ✔✔24 Skilled Nursing Facility ✔✔31 Nursing Facility ✔✔32 Hospice ✔✔34 Independent Laboratory ✔✔81 Medical Coding fraud is ✔✔financial losses estimated to range between $70 to $240 billion per year. Intentionally submitting incorrect coding and billing information is fraudulent and punishable by fines. ✔✔True Double billing ✔✔Submitting a single code multiple times when the procedure was only performed once. Upcoding ✔✔When a code has a higher reimbursement rate is submitted, when a lesser code is more appropriate. Downcoding ✔✔Assigning the patient with a lesser diagnosis and shows fake patient improvement, allowing for extended hospital stays that would not be granted otherwise. Unbundling ✔✔Using single codes to encompass multiple procedures, when entire procedure is covered by one code. 1986 False Claim Act (FCA) ✔✔Those charged with fraud may be assessed fines of $5,000.00 to $11,000.00 per claim. NCCI ✔✔National Correct Coding Initiative Edits NCCI promotes correct coding methodologies and control improper coding for inappropriate payments ✔✔in Part B claims AMA ✔✔American Medical Association NCCI contains one table for ✔✔Physician/Practitioners and one for Outpatient Hospital services CCI and MUEs tables ✔✔are combined into one table and include PTP code pairs that should not be reported together. PTP ✔✔Procedure to Procedure MUE ✔✔Mutually Unlikely Edits NCCI MUE program ✔✔prevents improper payment when services are reported with incorrect units of service/ What are MUE's? ✔✔Maximum number of units allowed under most circumstances for a single HCPCS/CPT code on same DOS. ABN's cannot be used ✔✔to seek payments for MUE's NCCI are updated ✔✔Quarterly NCCI is compromised of what two provider -type choices of PTP? ✔✔PTP Edits-Practitioners and PTP Edits NCCI is comprised of 3 Provider-type choices of MUEs ✔✔Practitioners MUEs; Durable Medical Equipment (DME), and Facility Outpatient PTP Edits Practitioners ✔✔submitted by physicians, non-physician practitioners, and ASCs (Ambulatory Surgery Centers) PTP Edits Hospital ✔✔Hospital hospitals, Skilled Nursing Facilities (SNF), Home Health Agencies (HHA) Outpatient Physical Therapy (OPT), Speech Language Pathology Providers, and Comprehensive Outpatient Rehabilitation Facilities (CORF) Practitioners MUEs ✔✔All physicians and other practitioner claims are subject to these edits DMEs MUEs ✔✔These edits are applied to claims submitted to DME MACs. Facility Outpatient MUEs ✔✔See UB-04 TOB POS

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