...Evaluation Compliance Strategies Medical Billing and coding compliance is very important to the billing world. Billing management starts at the first patient contact and ends only when the account has been paid in full. . In between, there are a series of important steps, each of which is critical for accurate billing and proper reimbursement. In this essay we are going to discuss the importance of the linkage code, implications of incorrect medical coding, and how physicians and payers fee are related to the billing compliance. We are also going to discuss what steps we can take to meet the compliance standards. When claims are filed correctly they will show the connection between the service being billed and the diagnosis code. The linkage code helps determine which procedure goes with which diagnosis code. If the linkage codes are not correct this will cause the claim to be denied. Linkage codes help the payer to determine the medical necessity for the service provided. Payers will determine the coverage by medical necessity. Services that are considered to be of nonmedical necessity are not covered under an insurance policy. It is important that the billing specialist be aware that different payers will have their own set of medical necessity edits. The implications of incorrect medical coding can cause issues for both the medical provider and the patient. Coding incorrectly can cause denial of claims. Providers would lose their patients trust, causing them to...
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...APPEAL NO 124 OF 1992 1 April 1993 Criminal Procedure -- Discharge not amounting to acquittal -- Accused under indefinite apprehension of recommencement of criminal proceedings -- Whether court could interfere with prosecutorial discretion not to further prosecute accused on a charge -- Discretion of court to direct that discharge shall amount to acquittal -- Nature of discretion -- Constitution of the Republic of Singapore art 35(8) -- Criminal Procedure Code (Cap 68) ss 184 & 336(1) The appellant was charged with four charges of voluntarily causing grievous hurt, criminal trespass, mischief and public nuisance. Before the commencement of the trial, the prosecution successfully applied for him to be discharged in order to enable him to complete a course of treatment at a drug rehabilitation centre, such discharge not amounting to an acquittal. On appeal, the appellant contended that the discharge ought to amount to an acquittal and in the alternative asked that the matter be reinstated and disposed of expeditiously on the grounds that it was unjust that he should be left under indefinite apprehension of the recommencement of these criminal proceedings. Held, dismissing the appeal: (1) When the public prosecutor decides to inform the court that he will not further prosecute a defendant upon a charge, he does so in the exercise of the discretionary power vested in him by art 35(8) of the Constitution and s 336(1) of the Criminal Procedure Code (Cap 68)('the CPC'). There can be no...
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...Central Government Act Section 141 in The Indian Penal Code, 1860 141. Unlawful assembly.-- An assembly of five or more persons is designated an" unlawful assembly", if the common object of the persons composing that assembly is- First.- To overawe by criminal force, or show of criminal force, 10[ the Central or any State Government or Parliament or the Legislature of any State], or any public servant in the exercise of the lawful power of such public servant; or Second.- To resist the execution of any law, or of any legal process; or Third.- To commit any mischief or criminal trespass, or other offence; or Fourth.- By means of criminal force, or show of criminal force, to any person to take or obtain possession of any property, or to deprive any person of the enjoyment of a right of way, or of the use of water or other incorporeal right of which he is in possession or enjoyment, or to enforce any right or supposed right; or Fifth.- By means of criminal force, or show of criminal force, to compel any person to do what he is not legally bound to do, or to omit to do what he is legally entitled to do. Explanation.- An assembly which was not unlawful when it assembled, may subsequently become an unlawful assembly. Central Government Act Section 447 in The Indian Penal Code, 1860 447. Punishment for criminal trespass.-- Whoever commits criminal trespass shall be punished with imprisonment of either description for a term which may extend to three months, or with fine which may extend...
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...is set free on that basis. The principle ensures that innocent people are not jail. Historical Background In doctrine it is shown that by the form given to the presumption of innocence in article 23 of the Constitution and the similar provisions in article 6 paragraph 2 of the European Convention and article 52 of the Criminal Procedure Code there is at least one contradiction regarding the moment up until to which the presumption functions. Jean Lemoine created the principle of presumption of innocence with the aim of protecting the defendant, based on the notion that many people are not guilty. This principle requires the judge to start by believing that the prosecution cannot prove its accusations. The principle means that: the accuser has the entire yoke of substantiation; the accused does not need to prove anything and the judge or jury should not get any negative conclusions from the accusations made by the prosecution against the defendant. All these presumptions known to as the golden thread, dictate that the verdict should be made solely from the evidence presented by the prosecution. It is the duty of the judge in ant criminal court to ensure that, there is a balance between the principle and the evidence presented by the prosecution. It is a hard task but a necessity in accordance with the law. The U.S Supreme court has stated...
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...case the patient has Humana. On the care the office manager needs to verify if a referral or pre-authorization needs to be obtained and then contact the respective Primary care physician and get his documentation. Insurance verification data and a copy of the insurance card is sent to the billing office. The billing office scans the information and saves the documents. The Scanning department retrieve the information and it sent to the appropriate departments. Pre-coders then enter the key-in codes for insurance companies, doctors and modifiers. Pre-coders also add insurance companies, referring doctors, modifiers, diagnosis codes and procedure codes. The coding team assigns the Numerical codes for current procedural terminology and the diagnosis code based on the description given by the provider. The charge team has competent individuals who would first enter the patient personal information form the information given. Also they check for the relationship of the diagnosis code and the current procedural terminology. They create a charge, according to the billing rules pertaining to the specific carriers and locations. All charges are accomplished within an agreed turnaround time, about 24 hours. The daily charge entry then needs to be audited to double check the accuracy. Claims are filed and information sent to the transmission department. This department prepares a list of claims that go out on paper and through the electronic media. Once claims are transmitted, confirmation...
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...Health Care Procedure Codes Purpose: To provide direction to Medical Management associates regarding FEP Non-Covered Health Care Codes Process: Locate the Non-Covered Health Care Procedure List * Log into FEP Direct * Scroll to the bottom under Support Processing & choose FAM Volume II * Scroll down under Chapters & Exhibits * Click on Exhibit 2-Non-Covered Health Care Procedure Codes OR * http://bluelink.wellpoint.com/bluelink/Top25Documents.aspx * Click on the Non-Covered Health Care Procedure Codes link Using the Non-Covered Health Care Procedure List * At the top of the list click on “Summary of Procedure Codes” * This will bring up a list of non-covered codes in specific groupings per CPT code. From this list you can choose the grouping your code would be in. FOR EXAMPLE: You are given CPT code 15839. This code falls between codes 15819-17380…Surgery: Integumentary System. Click on the category name and look through the list for your specific code. 15839 - Excision, excessive skin; other area is listed here as a Non Covered Health Care Procedure Code. UMRs WMDS * If all of the codes are found on the non-covered benefit list: * Load the case with the procedure codes * Indicate the non-covered benefit codes in the case note * Send to RN for review * If at least one code is found on the non-covered benefit list: * Load the case with the procedure codes * Indicate the non-covered benefit codes in the case...
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...document and attests to the fact that services were performed and may be billed for (Maines). Most encounter forms use "Progress" codes that are non-billable until the procedure is completed (i.e. root canals and prosthetics). Commonly these are CDT codes with "P" appended, while completed procedures have "C" appended, or have no prefix/ suffix. Depending on coverage, some procedures may need to be 'prior approved' by the third party carrier to be paid after completion. Terms for this are usually spelled out in the third party contracts. After the dentist formulates a treatment plan, it is submitted for Prior Approval, and approved services/ amounts are assigned some kind of code for billing upon completion (often called a PA number. Superbills & encounter forms help you save time and capture all charges from your patient visits. You can configure a custom Superbill for each provider in your practice, print Superbills with prepopulated patient information from the appointment scheduler, and use those Superbills to document the charges for your patient visits. By using forms customized to your unique needs, you can save time while capturing all charges. Superbills & Encounter Forms Superbills, also known as "Encounter Forms", "Charge Slips", or "Fee Tickets", are pre-printed forms that are used to document the charges, via procedure codes, associated with a patient visit along with...
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...more than 24 hours. Inpatient Medical Coders use the coding systems ICD-9-CM, ICD-10 as well as DRG (Diagnoses Related Groups). Inpatient Medical Coding requires greater knowledge and experience because the groupings and sequencing of codes for specific diagnoses and procedures in a hospital are significantly greater. Daily tasks usually include: • Review patient histories, operations, chart reviews, consultation and discharge summaries to support codes selected for billing. • Utilize ICD-9-CM and/or ICD-10 to select the diagnosis-related group (DRG) assignments for each case. • Identify mistakes in reports. • Enter coding information into electronic billing system. Many Inpatient Medical Coders work for hospitals, although insurance companies and long-term health-care facilities may also employ inpatient coders. They typically must have at least 2 years of experience to be hired and may work at the facility or off-site in their homes. Hours vary based on the employer. Accuracy is critical in this position, as much of a hospital’s revenue depends on the correct coding of the diagnoses, procedures, and treatments administered. Coders often interact with physicians, nurses and other medical professionals in order to select the proper codes. Critical thinking and communication skills, great attention to detail and the ability to manage pressure without error are essential. Training: • High school diploma or certificate beyond high school and increasingly employers are specifying...
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...The following paper will be discussing the 4 main steps to ensure that the ICD codes are accurate. This paper will also be discussing the four steps that are necessary to establish the proper ICD-9-CM code. There are many ways that this paper will explain what is right to do and gives you a good source through a book that you can just gather all your information from. Step-by Step Medical Code Book by Buck is such an incredible book to get your sources from. ICD-9-CM code means International Classification of Disease, 9th edition. This is a standardized classification of disease, injuries and causes of death, by etiology and anatomic localization and anatomic localization and codified into a 6 digit number. When given any of these symptom assigned number’s this allows many clinicians and many involved people that have the same common language with in the medical field. The ICD-9-CM has been used in this country since 1973 for morbidity applications. This will help continue the hospital or anyone dealing with medical to be organized and just improve more and more. There are 8 steps to follow to have an accurate coding system. We are going to discuss the top 4 that are important. First one is to identify the main term in the diagnostic statements meaning you would to make sure that you have the correct code. Always do a double check when finding the correct code. The second step to an accurate code is you would need to locate the main term in the Alphabetic index. The Index...
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...surgical codes, based on clinical documentation from a healthcare provider, which is used for review and validation. With the assistance of these new automation tools, coding or HIM professionals can easily translate clinical data input into useful clinical data output. Increased amounts of clinical coding is done by machines, which saves time and human participation for more complex coding cases and data analysis tasks. Factors, such as advances in natural language processing, EHR adoption, compliance issues and mandates for labor – intensive administrative reporting processes reduction, influenced the demand of CAC. Traditionally, clinical documentation (whether paper or electronic) is analyzed by a coder, translated into the appropriate ICD – 9 CM or CPT/HCPCS codes with the help of coding books or encoders and entered into a database. These new coding automation tools assists HIM professionals in translating data by automated code assignment instead of manual review and translation alone. As early as the 1950s, the technology of CAC – enabled tools, particularly Natural Language Processing (NLP), started with formal language theory. Throughout this time, technological progress was slow but technology has rapidly progressed and is constantly advancing at an exponential rate since the 1990s. Coding is a difficult task because it has a four- dimensional complexity. First, coding rules’ volume and intricacy makes selecting the right diagnosis/ procedure code and code modifiers...
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...THE ARGUMENT FOR A CONSTITUTIONAL RIGHT TO REPRESENTATION AT BAIL HEARINGS IN ALL CRIMINAL CASES IN STATE COURT The right to legal representation is generally accepted in the United States as a Constitutional right guaranteed to everyone. The Supreme Court promised the right to counsel to “ any person haled into court” in the infamous Gideon v Wainwright case. This case was instrumental in advancing the rights of indigent defendants through its proclamation that the Sixth Amendment right to counsel in criminal proceedings should also apply to State Courts. However, Gideon’s promise to counsel has yet to completely guarantee equal access to justice when first appearing at judicial proceedings in state courts. Although defendants who can afford lawyers will usually hire one from the onset of a criminal proceeding, the right to counsel for indigent defendants (i.e. a state-provided attorney) is interpreted as attaching at varying stages of a prosecution in different states. Only eight states guarantee indigent defendants the right to legal counsel at the initial bail hearing. Representation at the initial bail hearing is critical as a lawyer’s intervention is crucial for obtaining a defendant’s release and for protecting a defendant’s due process right (guaranteed in the Fourteenth amendment) against an unreasonable denial of liberty during pretrial detention. The lack of counsel in pretrial proceedings can result in numerous consequences; some include a high number of pleas...
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...Civil Procedure v. Criminal Procedure ENC 1102 34 Week 11 Individual Work Civil Procedure v. Criminal Procedure Civil procedure relates to the process where two parties bring a case to the court for a decision on a particular problem. These problems can include but are not limited to divorces, estate distribution, work men’s comp., injury cases, or even matters such as discrimination in the workplace. Criminal procedure applies to the process where the state or federal government is charging and trying someone for a crime that was committed (Civil Procedure, 2012). The rules in civil procedure are different than those in criminal procedure because the actions that need to be taken are different. Firstly, civil procedure requires that a civil case must begin by filing a complaint. The complaint is then, served to the offending party. Once the defending party receives the complaint, they then drafts and files an answer with the court. A party in a civil case can be anyone including people, businesses, and government personnel. When the parties go in front of the court in a civil case, it is to determine whether a person was injured and if they were injured, how much should be compensated for that injury. All of this information pertaining to the civil case is specifically drafted into the court documents (American Bar, 2012). Civil cases, also, have some Constitutional protection in place. For example, the parties involved in a case must file and receive consent of the...
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...Supreme Court of the United States, In the case of the Supreme Court of the United States, Michael D. Crawford v. Washington. Michael Crawford was tried for assault and attempted murder for stabbing a man who was named, Kenneth Lee. Crawford stabbed Lee at his apartment on on August 5,1999. Police arrested petitioner later that night. Crawford claimed he had acted in self-defense when he believed Lee had picked up a weapon. Lee denied doing anything that might make Crawford believe he was trying to attack him. Michael Crawford contended that Lee had attempted to rape his wife, Sylvia. The police arrested him for the stabbing, and after giving both Michael and his wife, Sylvia, Miranda warnings, they interrogated both husband and wife twice. The statement Michael challenged under the Confrontation Clause came from a tape recorded interrogation of Sylvia. In her second interrogation, she gave a version of the fight between Michael and the alleged victim that at least appeared inconsistent with her husband’s self-defense claim. Sylvia’s tape recorded statement was introduced at trial against Michael even though he had no opportunity for cross examination. In reviewing the statement’s admission by the trial court, the Washington Court of Appeals and Washington Supreme Court applied slightly different tests grounded in the framework described by...
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...all kinds of reasons such as – * Systemic delays. * Grossly inadequate number of judges8 and prosecutors. * Absence or belated service of summons on witnesses. * Presiding judges proceeding on leave. * Remands being extended mechanically due to lack of time and patience with the presiding judge. * Inadequacy of police personnel and vehicles which prevents the production of all prisoners on their due dates. * Many a times, the escorting police personnel merely produces the remand papers in the courts instead of actually producing the prisoner in front of the magistrate. This practice is widely reported, notwithstanding the strict requirement of the law in Section 167[2][b] of the Criminal Procedure Code, 1973 [CrPC] which says that – ‘No Magistrate shall...
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...OF CRIMINAL PROCEDURE CODE Criminal Procedure Code, 1973, S.2(g) - Inquiry - “Every inquiry, other than a trial, conducted under this Code by a magistrate or court” refers to the pre trial inquiry. (Pritish Vs State of Maharashtra) 2002(2) Criminal Court Cases 174 (S.C.) Criminal Procedure Code, 1973, S.2(g) - Inquiry - Trial - Inquiry is defined by section 2 (g) as 'every inquiry, other than a trial' - Trial not defined - Trial is clearly distinguishable from inquiry - Trial is distinct from inquiry and inquiry must always be a forerunner to the trial. (Moly & Anr. Vs. State of Kerala ) 2004(2) Criminal Court Cases 514 (S.C.) Criminal Procedure Code, 1973, S.2(g) - Trial and enquiry - Distinction - Trial is distinct from inquiry and inquiry must always be a forerunner to the trial. (Vidyadharan Vs State of Kerala) 2004(1) Criminal Court Cases 516 (S.C.) Criminal Procedure Code, 1973, S.2(h) - “Investigation” - It includes all the proceedings under the Code for the collection of evidence conducted by a police officer or by any person (other than a Magistrate) who is authorised by a Magistrate in this behalf - It ends with the formation of the opinion as to whether on the material collected, there is a case to place the accused before a Magistrate for trial and if so, taking the necessary steps for the same by filing of a charge-sheet under Section 173 Cr.P.C. (Union of India Vs Prakash P.Hinduja & Anr.) 2003(2) Apex Court Judgments 205 (S.C.) Criminal Procedure...
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