Member Organization:
|
|
- Darren Neal
- 5 years ago
- Views:
Transcription
1 Christine M. Boras, CHC, CFE, MBA Laboratory Compliance Plans XYZ I. General A. The purpose of this Review is to insure that the Laboratory is adhering to their approved Compliance Policies and Procedures and to determine that these Policies and Procedures are adequate to accomplish their objectives and provide adequate internal and operational controls. See the Planning Memo at for further details. B. Obtain a copy of the Compliance Polices and Procedures referred to above, include them in the workpapers and become thoroughly familiar with them. C. Prepare an Engagement Letter and issue to the appropriate management personnel for notification of the Review. II. Planning A. Arrange a meeting with Laboratory Management to discuss the current policies and procedures used in practice, note any differences from the written policies. B. Formulate a brief narrative of the current procedures and/or processes and compare them to the written polices and procedures. Note any variations. Include the narrative in your workpapers. C. Obtain and review copes of recent audit/survey reports and consultant reports (as applicable) issued by various agencies that pertain to the department/facility. Include them in your workpapers. D. Obtain a copy of the departments/facilities respective Corrective Action Plan(s), if applicable, and discuss with appropriate management personnel its status. Include a copy of the plan(s) in your workpapers. E. Review prior year s compliance review report and workpapers, if applicable, and discuss with appropriate management personnel. Assess status of Corrective Action Plan(s) if applicable.
2 Laboratory Compliance Plans Christine M. Boras, CHC, CFE, MBA III. Observation and Prospective Compliance Testing A. Observation/Prospective Sample Testing 1. Inquire with Lab Management how physicians are made aware by the Lab that Medicare will only pay for tests that meet Medicare coverage criteria. Obtain a copy of the most recent list of tests that pertain to the above and include in workpapers. 2. Requisition Design: Inquire with Lab personnel the Lab ordering processes and include in the narrative. a. Obtain and review a blank lab requisition to ensure the following criteria are included on the order:! Patient s name! Date of order! Patient s insurance! Address! ICD-9-CM code! Test to be performed! Social Security number! Sex! Date of Birth! Review of ABN appropriateness! Review of Notices of Non-Coverage appropriateness! Physician s signature (must be legible) b. Discuss process taken in the event that there is missing information on a lab order from the criteria noted in 2.a. above (e.g., unsigned by the ordering physician). c. Inquire procedure followed in the event that an ordered Laboratory test can not be performed due to unclear physician orders, specimen integrity or insufficient quantities. d. Inquire and review processes to ensure a prospective sample is selected for compliance testing. e. Prospectively select orders to ensure the following:! All the data criteria listed in 2.a. above is documented.! Signature of Physician (or PA, NP, FNP) (Handwritten, Initials, or Electronic allowed) (No stamps permitted; No LPN or RN signatures)
3 Christine M. Boras, CHC, CFE, MBA! Diagnosis codes are linked to the service. Review Program Laboratory Compliance Plans f. Prospectively select charts to ensure the following:! A written order exists.! Services are documented and performed. 3. Inquire with Lab Management what policies and procedures have been implemented that delineates follow-up actions and resolution for incomplete, inaccurate or non-existent diagnosis information. 4. Canceled Orders: Review with Lab personnel the process of how canceled orders are handled in the Lab and how they get canceled. Inquire whether there are any written policy and procedures for canceled orders. If so, include in workpapers. a. Determine how large the pool is of canceled orders in a given period and their frequency. 5. Verbal Orders: Inquire with Lab personnel the policy and procedure regarding verbal orders and obtain the most recent copy of the written policy for workpapers. a. Inquire concerning the following:! A log or form that tracks verbal orders containing the following criteria:! Date phoned! Patient name! Tests to be performed! ICD-9 code diagnosis! Physician name and phone #! Medical Record number b. Inquire if a formal policy and procedure has been established to follow-up and monitor verbal orders to verify receipt of a written, signed order by the physician is obtained by the lab within 30 days following receipt of the verbal order, as per CLIA Regulations. c. Prospectively select Verbal orders received to ensure documentation, monitoring and follow-up procedures are adequate.
4 Christine M. Boras, CHC, CFE, MBA Laboratory Compliance Plans d. Lab Order Add-Ons (Verbal): Review the process and frequency for handling Verbal Lab Order Add-Ons from physicians and others, as applicable. a. Determine whether tracking mechanism(s) are adequate and accurate for appropriate follow-up 6. Standing Orders: a. Inquire whether written policies and procedures have been developed to ensure a tracking system to monitor standing orders has been implemented. b. Review tracking system documentation to monitor for validity parameters and expiration of the standing orders (valid for a period of six months from the date indicated on the order). c. Inquire how the physician is notified to ensure that new standing orders are provided before any testing is performed by the lab if the prior order has expired. 7. Notice to Physicians: Ensure the Lab is providing physicians/providers, annual written notice of the following:! The requirements necessary for the Lab to provide service as noted above in A.2.a.! Copy of Medicare Medical Necessity Policy.! List of individual components of each lab profile that includes a multichannel chemistry test or other automated multiple test results (e.g ).! CPT-4 or HCPCS codes which the lab uses to bill Medicare for each profile.! Medicare National Limitation Amount for each CPT-4 code used to bill Medicare for each profile and its components, if available.! Description of how the lab will bill Medicare for each profile.! Inquire procedure followed whenever any
5 Christine M. Boras, CHC, CFE, MBA information is incomplete of missing.! Ensure a monitoring control system has been developed to track physician notices adequately. Laboratory Compliance Plans 8. Physician Acknowledgment: Inquire procedure followed to ensure physician acknowledgment in A.7. of above. 9. Action Plans: Review for status and progress of action plan steps for the following, as applicable:! Program Action Plan! Improvement Action Plan! Environment Lab Plan! Lab Risk Matrix IV. Training and Education for Physician s and/or Lab Personnel: A. Inquire as to types of training and education offered to all Lab personnel & Physicians, how often; are there any Policies and Procedures in place for the following:! Standards of Conduct! Diagnosis Code Assignment (ICD-9)! Medical Necessity guidelines! Verbal Orders! Canceled Orders! Standing Orders! Unorderable tests/unacceptable Specimens! Notice to Physicians! ABN s! Notice of Non-Coverage (NNC)! Tests ordered and performed! Steps to manage Non-Compliance Physicians! Regulatory Notification (State, CLIA, Federal, etc.) V. Record Retention: A. Inquire and review the process and procedure for Retention of Records (i.e., original physician order, ABN/Waiver, 7 year period etc.) as per policy and Dept. of Health rules and regulations. Determine the adequacy for the maintenance of the records retention process/procedure.! ABN/Waiver! Notice of Non-Coverage (NNC)! Notice of Non-Coverage via Telephone! Physician Orders! Verbal Orders! Canceled Orders! Standing Orders
6 I. General Christine M. Boras, CHC, CFE, MBA! Notice to Physicians & Physician Acknowledgment! Test Utilization! Department Compliance E & T Logs, Agendas, etc.! Results of Lab Orders Laboratory Compliance Billing A. The purpose of this Review is to insure that the Laboratory is adhering to their approved Compliance Policies and Procedures and to determine that these Policies and Procedures are adequate to accomplish their objectives and provide adequate internal and operational controls. See the Planning Memo at for further details. A. Obtain a copy of the Compliance Polices and Procedures referred to above, include them in the workpapers and become thoroughly familiar with them. A. Prepare an Engagement Letter and issue to the appropriate management personnel for notification of the Review. II. Planning A. Arrange a meeting with Laboratory Management to discuss the current policies and procedures used in practice and the current polices and procedures used in the coordination of Lab Services with Nursing Homes, note any differences from the written policies. B. Formulate a brief narrative of the current procedures and/or processes and compare them to the written polices and procedures. Note any variations. Include the narrative in your workpapers. C. Obtain and review copes of recent audit/survey reports issued by various agencies that pertain to the department/facility. Include them in your workpapers. E. Obtain a copy of the departments/facilities respective Corrective Action Plan, if applicable, and discuss with appropriate management personnel its status. Include a copy of the plan in your workpapers. F. Review prior year s compliance review report and workpapers, if applicable, and discuss with
7 Christine M. Boras, CHC, CFE, MBA appropriate management personnel. Assess status of Corrective Action Plan if applicable. Laboratory Compliance Billing III. Observation and Prospective Compliance Testing A. Observation/Prospective Sample Testing 1. Tests ordered and performed: Inquire what procedure and policy is followed to monitor added and deleted tests to ensure proper billing. Also see III.A.2.c. in the Laboratory Compliance Plan review program. Review for implementation and adequacy. a. Verify monitoring process to ensure all tests ordered were performed. b. Verify monitoring process for added and deleted tests. c. Assignment of CPT-4 or HCPCS codes accurately link test ordered and performed. 2. Duplicate Charges: Inquire what procedures and monitoring controls have been implemented to ensure duplicate charges do not occur (i.e., outpatient testing once for the same date of service/ encounter). a. Verify monitoring controls, documents/logs, and procedures for adequacy. b. Prospectively select order/encounters/ requisitions or other documents as applicable for sample testing to ensure duplicate charges do not occur. 3. Venipuncture Charges: Inquire what procedures and monitoring controls have been implemented to prevent duplicate venipuncture charges and that venipunctures performed by non-laboratory personnel (if applicable) are not billed as part of the laboratory service (i.e., one venipuncture charge per patient/per date of service).
8 Christine M. Boras, CHC, CFE, MBA a. Verify monitoring controls, documents/logs, and procedures for adequacy. b. Prospectively select order/encounters/ requisitions or other documents as applicable for sample testing to ensure duplicate venipuncture charges do not occur. Laboratory Compliance Billing 4. Appropriate Prices: Inquire what procedures and policy has been developed and implemented to ensure that lab testing services that are sold directly to physician s exceeds the tests costs. c. Obtain a copy of the policy and review to ensure completeness and appropriateness. d. Review the implementation and monitoring controls of the policy for adequacy and completeness. e. Inquire and review how discounted pricing arrangements are documented, reviewed, and monitored to assure avoidance of anti-kickback issues. 5. Test Utilization Monitoring: Inquire how the lab is retaining and analyzing test utilization data from year to year by CPT or HCPCS codes for the top 30 tests performed. a. Review and verify if any tests exceeded 10% of the previous year s amount and inquire what actions and procedures were taken to ascertain the cause of the increase. b. Inquire how a Prospective review can be performed for test utilization monitoring accuracy and completeness. If possible, perform a prospective sample test. 6. Reflex testing: Inquire how reflex testing is documented (clearly stating the condition under which the reflex testing is performed) and the procedure to ensure unnecessary reflex tests are not performed as a result of the first test. a. Verify what controls are in place to ensure compliance, medical necessity, and are not excessive.
9 Christine M. Boras, CHC, CFE, MBA Audit/ Review Program Laboratory Compliance Billing 7. Unacceptable Specimens/Unorderable tests: Inquire what procedure is followed to ensure the patient is not billed for laboratory tests which:! could not be performed due to the specimen collected was insufficient or unacceptable for analysis;! test request which may be incorrect or for testing that is not offered by the lab. (Include specimens which were obtained by lab personnel, hospital staff or submitted to the lab from an outside source). 8. Co-Payments & Deductibles Inquire what procedures have been implemented to ensure that co-payments and deductibles are not routinely waived. 9. Drop-off Specimen Orders Inquire what procedure has been implemented regarding drop-off specimens from nursing homes, outpatient clinics, or an outside source ( Dr. Drops ). <note> I/A is reviewing prospective billing for outpatient clinics as a Medicaid Review-Follow-up a. Inquire how non-visit orders are processed, documented and tracked. Determine adequacy of procedures. 10. Processing Split Orders (UMA/UHSH) Inquire what procedure is followed when a portion of an individuals lab test(s) is performed by DEF s lab and another portion is performed by XYZ s lab. 11. Lab Order Results & Billing Inquire what procedure is followed to to ensure lab orders are billed based on the actual service performed and
10 resulted vs. when the lab requisition was entered into billing system. Christine M. Boras, CHC, CFE, MBA 12. Hematology, Blood Chemistry & Urine Tests Inquire what procedure is followed regarding billing of Hematology, Blood Chemistry, and Urine tests. Laboratory Compliance Billing 13. ABN Authorization for Mental Health Services Inquire what procedure is followed to obtain a verbal authorization for Mental Health Services. 14. Denied Claims: Review protocols, Action Plans (if applicable), and processes with Lab management personnel a. Obtain & Review data evidencing denied claims are worked and have been reduced within compliance. b. Obtain & Review data for amounts reimbursed as a result of the step above. c. Discuss challenges/concerns with Lab management personnel. 15. Lab Software Systems Review for Data Integrity of the Lab software system to ensure compliance. a. Review processes that flag a mis-diagnosis to a CPT code.
11 Christine M. Boras, CHC, CFE, MBA Advanced Beneficiary Notification (ABN) Laboratory I. General A. The purpose of this Review is to insure that the Laboratory is adhering to their approved Compliance Policies and Procedures and to determine that these Policies and Procedures are adequate to accomplish their objectives and provide adequate internal and operational controls. See the Planning Memo at for further details. B. Obtain a copy of the Compliance Polices and Procedures referred to above, include them in the workpapers and become thoroughly familiar with them. C. Prepare an Engagement Letter and issue to the appropriate management personnel for notification of the Review. II. Planning A. Arrange a meeting with Laboratory Management to discuss the current policies and procedures used in practice, note any differences from the written policies. B. Formulate a brief narrative of the current procedures and/or processes and compare them to the written polices and procedures. Note any variations. Include the narrative in your workpapers. D. Obtain and review copes of recent audit/survey reports issued by various agencies that pertain to the department/facility. Include them in your workpapers.
12 Christine M. Boras, CHC, CFE, MBA F. Obtain a copy of the departments/facilities respective Corrective Action Plan, if applicable, and discuss with appropriate management personnel its status. Include a copy of the plan in your workpapers. G. Review prior year s compliance review report and workpapers, if applicable, and discuss with appropriate management personnel. Assess status of Corrective Action Plan if applicable. Advanced Beneficiary Notification (ABN) Laboratory III. Observation & Prospective Compliance Testing A. Observation 1. Inquire and observe (if possible) the processes of how and when ABN s are executed BEFORE the test has been performed for the patient. If applicable, note differences for both Inpatient and Outpatient. 2. Inquire as to what happens in the event that a patient refuses to sign an ABN.! Is the test still performed?! Is it referred back to the physician? 3. Inquire as to whether the reason for the belief that payment may be denied is specified. B. Prospective Sample Testing 1. Prospectively select ABN s for those Medicare patients who have had Laboratory tests for both Inpatient and Outpatient (as applicable). 2. Ensure selection includes Laboratory tests ordered which did not have an ABN signed as well as tests which did have an ABN signed to ensure ABN are executed appropriately. 3. Prospectively select charts to ensure
13 Christine M. Boras, CHC, CFE, MBA the following:! A written order exists.! Services are documented and performed. 4. Cross-reference the laboratory test ordered with the diagnosis code on the Lab s master list of approved laboratory tests covered by Medicare; if both are listed an ABN waiver is not needed. Advanced Beneficiary Notification (ABN) Laboratory 5. If the laboratory test ordered is not covered by Medicare verify the following information is indicated on the Outpatient Laboratory Order Form under Medicare Notice of Patient s Responsibility (ABN / Waiver): a. Test Name b. Patient s signature c. Witness s signature Note that routine screening and physicals are not covered by Medicare, therefore an ABN must be signed by the patient. 6. Blanket ABN s: Verify that ABN s are NOT given to every patient and that beneficiaries are NOT asked to sign blanket ABN s. 7. Review a representative sample of denials to ensure adequate implementation of the issuance of ABN s. IV. Conclusion: Date
14 Reviewer(s) Christine M. Boras, CHC, CFE, MBA Date Corporate Compliance Officer
CDx ANNUAL PHYSICIAN CLIENT NOTICE
CDx ANNUAL PHYSICIAN CLIENT NOTICE - 2018 CDX Diagnostics is providing this annual notice in accordance with the recommendations made by the Office of Inspector General (OIG) as part of our CDx Compliance
More informationMartin Health System Stuart, Florida Laboratory Services. Laboratory Services and Policies
Martin Health System Stuart, Florida Laboratory Services Laboratory Services and Policies Service Commitment: It is the goal of the Martin Health System s Clinical Laboratory to provide the medical community
More informationBilling Information. Patient Billing Information Patient Demographic Client / Ordering Physician Information Ordering Tests/Panels
Billing Information Patient Billing Information Patient Demographic Client / Ordering Physician Information Ordering Tests/Panels This section provides instructions on how to process a patient and fill
More informationCOMPLIANCE MONITORING CHECKLIST
HOSPITAL COMPLIANCE MONITORING CHECKLIST Return To: Year Ending: December 31, 2005 Email: Affiliate: Person Completing: Fax: All "No" answers should include an explanation in the General Comments column.
More informationCloning and Other Compliance Risks in Electronic Medical Records
Cloning and Other Compliance Risks in Electronic Medical Records Lori Laubach, Partner, Moss Adams LLP Catherine Wakefield, Vice President, Corporate Compliance and Internal Audit, MultiCare 1 AGENDA Basic
More informationTherapies (e.g., physical, occupational and speech) Medical social worker (MSW) 3328ALL0118-F 1
1. Q: Why is Humana implementing this utilization management (UM) program? A: Humana is implementing this program to help coordinate home health care for its Medicare Advantage members in Oklahoma and
More informationPAC Waiver. eqhealth Solutions PAC Waiver Authorization Process
PAC Waiver eqhealth Solutions PAC Waiver Authorization Process January 2015 1 Purpose of Presentation Upon completion of the webinar, participants will be able to: 1. Prepare and submit PAC Waiver Requests
More informationAddressing Documentation Insufficiencies
Objectives Addressing Documentation Insufficiencies ICAHN June 9,2015 Glenn Krauss, BBA, RHIA, CCS, FCS, PCS,CCS-P, CPUR, C-CDI, CCDS, C- DAM Understand and appreciate physician frustrations with the EHR
More informationChronic Care Management. Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky
Chronic Care Management Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 502.992.3511 sshover@blueandco.com Agenda Chronic Care Management (CCM) History Define Requirements
More informationOFFICIAL NOTICE DMS-2003-A-2 DMS-2003-II-6 DMS-2003-SS-2 DMS-2003-R-12 DMS-2003-O-7 DMS-2003-L-8 DMS-2003-KK-9 DMS-2003-OO-7
Arkansas Department of Human Services Division of Medical Services Donaghey Plaza South PO Box 1437 Little Rock, Arkansas 72203-1437 Internet Website: www.medicaid.state.ar.us Telephone: (501) 682-8292
More informationPayment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL
Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Effective Date: 6/2017 Last Review Date: See Important Reminder at the end of this policy for important
More informationMedicare Noncoverage Notices
March 2014 This job aid is intended to assist home health and hospice clinicians in: Understanding and complying with regulations for issuing required Medicare notices at the time of termination and change
More informationHome Health & HP Provider Relations
Home Health & Hospice HP Provider Relations October 2010 Agenda Session Objectives Home Health Benefit Coverage Billing Overhead Multiple Visits Most Common Denials Hospice Benefit Coverage Election/Revocation/Discharge
More informationOptima Health Provider Manual
Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating
More informationChapter 11 Section 3. Hospice Reimbursement - Conditions For Coverage
Hospice Chapter 11 Section 3 Issue Date: February 6, 1995 Authority: 32 CFR 199.4(e)(19) 1.0 APPLICABILITY This policy is mandatory for reimbursement of services provided by either network or nonnetwork
More informationChapter 15. Medicare Advantage Compliance
Chapter 15. Medicare Advantage Compliance 15.1 Introduction 3 15.2 Medical Record Documentation Requirements 8 15.2.1 Overview... 8 15.2.2 Documentation Requirements... 8 15.2.3 CMS Signature and Credentials
More information50 Essential Forms for Laboratory Compliance
Essential Forms for Laboratory Compliance With contributing editor Kelly A. Briganti, JD Achieve and demonstrate lab compliance with this book and CD-ROM set! Additional HCPro titles for your laboratory
More informationQuarterly CERT Error Findings Report WPS GHA Part B J8 MAC ~ Indiana and Michigan ~
Quarterly CERT Error Findings Report WPS GHA Part B J8 MAC ~ Indiana and Michigan ~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed April 1, 2017, through June 30,
More informationMedicare Preventive Services
Medicare Preventive Services Presented by Part B Provider Outreach & Education December 16, 2015 Event Instructions Today s event is a teleconference Slides will not be advanced during the presentation
More informationABOUT AHCA AND FLORIDA MEDICAID
Section I Introduction About AHCA and Florida Medicaid ABOUT AHCA AND FLORIDA MEDICAID THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION The Florida Agency for Health Care Administration (AHCA or Agency)
More informationArchived SECTION 13 - BENEFITS AND LIMITATIONS. Section 13 - Benefits and Limitations
SECTION 13 - BENEFITS AND LIMITATIONS 13.1 BENEFITS AND LIMITATIONS...4 13.1.A AUTHORIZATION...4 13.1.B DEFINITION...4 13.1.C PROVIDER PARTICIPATION REQUIREMENTS...4 13.1.C(1) Hospice-Nursing Facility
More informationJill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883
Jill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883 This material is designed to offer basic information for coding and billing. The information presented here is based on
More informationHealthChoice Radiology Management. March 1, 2010
HealthChoice Radiology Management March 1, 2010 Introduction Acting on behalf of our Medicaid customers in Maryland (HealthChoice), UnitedHealthcare has worked with external physician advisory groups to
More informationConnecticut Medical Assistance Program Refresher for Hospice Providers. Presented by The Department of Social Services & HP for Billing Providers
Connecticut Medical Assistance Program Refresher for Hospice Providers Presented by The Department of Social Services & HP for Billing Providers 1 Training Topics Hospice Agenda HIPAA 5010 Hospice Form
More informationMedical Management Program
Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina
More informationThe presenter has owns Kelly Willenberg, LLC in relation to this educational activity.
Kelly M Willenberg, MBA, BSN, CCRP, CHC, CHRC 1 The presenter has owns Kelly Willenberg, LLC in relation to this educational activity. 2 1 Medical Necessity when you submit claims Coding for qualifying
More informationProcedure Code Job Aid
Procedure Code 99211 Job Aid Definition for 99211: Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually,
More informationPersonal Care Services (PCS): An Overview of PCS and The Request for Independent Assessment for PCS Attestation of Medical Need Form (DMA 3051)
Personal Care Services (PCS): An Overview of PCS and The Request for Independent Assessment for PCS Attestation of Medical Need Form (DMA 3051) January 2018 OBJECTIVES At the conclusion of this training,
More informationSection 7. Medical Management Program
Section 7. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.
More informationCare Plan Oversight Services and Physician Services for Certification
Education Makes the Difference Care Plan Oversight Services and Physician Services for Certification and Recertification of Medicare-Covered Home Health Services A CMS CONTRACTED INTERMEDIARY CARRIER The
More informationElectronic Health Records - Advantages and Pitfalls of Documentation
Electronic Health Records - Advantages and Pitfalls of Documentation Kansas City, KS HCCA Regional Conference September 25, 2015 1:00 P.M. 2:00 P.M. Presented by: Cynthia A. Swanson, RN, CPC, CEMC, CHC,
More informationInpatient orders and Physician Certification MUST BE authenticated PRIOR to discharge No EXCEPTIONS.
2 Midnight Rule for InPatient Admission On August 2, 2013 the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS- 1599-F) updating Medicare payment policies which modifies and clarifies
More informationCORPORATE COMPLIANCE POLICY AUDIT & CROSSWALK WHERE ADDRESSED
QUALITY OF CARE Sufficient Staffing Inadequate staffing levels or insufficiently trained (inadequate clinical expertise) or insufficiently supervised staff providing medical, nursing, and related services
More informationUB-92 Billing Instructions
August 26, 2005 UB-92 Billing Instructions 2005 Hospital Provider Workshop Conduent MS Medicaid Project Government Healthcare Solutions Objective & Definition To explain how to complete a UB-92 claim form
More informationLaboratory Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2017 DXC Technology Company. All rights reserved.
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Laboratory Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 3 6 P U B L I S H E D : J U N E 2 9, 2 0 1 7 P O L I C I
More informationABOUT FLORIDA MEDICAID
Section I Introduction About eqhealth Solutions ABOUT FLORIDA MEDICAID THE FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION The Florida Agency for Health Care Administration (AHCA or Agency) is the single
More informationRegulatory Compliance Risks. September 2009
Rehabilitation Regulatory Compliance Risks September 2009 1 Agenda - Rehabilitation Compliance Risks Understand the basic requirements for Inpatient Rehabilitation Facilities (IRFs) and Outpatient Rehabilitation
More informationProfessional Assoc. of Healthcare Coding Specialists PAHCS Presented by Marge McQuade, CMSCS, CMM, CPM Director of Education
Advanced Beneficiary Notice ABN Professional Assoc. of Healthcare Coding Specialists PAHCS Presented by Marge McQuade, CMSCS, CMM, CPM Director of Education EFFECTIVE MARCH 1, 2009 Providers must notify
More informationMEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE
MEDICAL ASSISTANCE BULLETIN COMMONWEALTH OF PENNSYLVANIA * DEPARTMENT OF PUBLIC WELFARE SUBJECT BY NUMBER: ISSUE DATE: September 8, 1995 EFFECTIVE DATE: September 8, 1995 Mental Health Services Provided
More informationCorCare PPO Provider Manual. Updated 12/19/2016
CorCare PPO Provider Manual 2017 Updated 12/19/2016 TABLE OF CONTENTS TABLE OF CONTENTS 1. Summary of Procedures, Resources, Claims Submissions... 3 2. Claims Completion... 4 3. Prepayment and Balanced
More informationCompliant Documentation for Coding and Billing. Caren Swartz CPC,CPMA,CPC-H,CPC-I
Compliant Documentation for Coding and Billing Caren Swartz CPC,CPMA,CPC-H,CPC-I caren@practiceintegrity.com Disclaimer Information contained in this text is based on CPT, ICD-9-CM and HCPCS rules and
More informationSUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE
SUNY DOWNSTATE MEDICAL CENTER UNIVERSITY HOSPITAL OF BROOKLYN POLICY AND PROCEDURE No: LAB-1 Subject: PROCEDURES FOR HANDLING Page 1 of 6 INPATIENT AND OUTPATIENT LABORATORY Prepared by: Dynesdal Wint
More informationProvider-Based RHC Billing June 8, 2018
Provider-Based RHC Billing June 8, 2018 Sharon Shover, CPC, CEMC 502.992.3511 Provider-Based RHC Billing Agenda RHC Encounters Payment for RHC Services Same Day Visits Revenue Codes CG Modifier & QVL Non-RHC
More informationHi-Tech Software and the Triple Check Process
Hi-Tech Software and the Triple Check Process Contents How Hi-Tech Software Assists the Triple Check Process... 1 Census... 1 Stay Tables... 2 Hi-Tech Helps you Avoid Incorrect Assessments... 3 Diagnosis
More information8/28/2014. Compliance and Practical Challenges When Using Scribes: Just What the Doctor Ordered? Objectives of the Presentation
Compliance and Practical Challenges When Using Scribes: Just What the Doctor Ordered? Jerry Williamson MD. MJ. CHC. LHRM Objectives of the Presentation Definition of a Scribe Duties of a Scribe Regulatory
More informationMS Envision Web Portal Homepage
Web Portal Review MS Envision Web Portal Homepage http://ms-medicaid.com Provider Tab (Non-Secure) Web Portal Non-Secure Features What s New Late Breaking News Current Medicaid Bulletin Provider Lookup
More information99 - No response error No Medical records were received.
1 May 2017 HCPCS Code Type Error Error Identified by CERT Anesthesia Services 00140 MISSING: 1) Signature attestation statement or signature log for the illegibly signed Pre-Anesthesia evaluation and illegibly
More informationBilling Policies & Procedures
Billing Policies & Procedures ANATOMIC PATHOLOGY I. INTRODUCTION UChicago MedLabs default billing policy is to bill the client for our testing services. However, as a service to our clients, UChicago MedLabs
More informationLIFE SCIENCES CONTENT
Model Coding Curriculum Checklist Approved Coding Certificate Programs must be based on content appropriate to prepare students to perform the role and functions associated with clinical coders in healthcare
More informationSection VII Provider Dispute/Appeal Procedures; Member Complaints, Grievances, and Fair Hearings
Section VII Provider Dispute/Appeal Procedures; Member Complaints, Grievances, and Fair Hearings Provider Dispute/Appeal Procedures; Member Complaints, Grievances and Fair Hearings 138 Provider Dispute/Appeal
More informationLessons Learned in the EHR
Lessons Learned in the EHR Lori Laubach, Partner Health Care Consulting Group 1 The material appearing in this presentation is for informational purposes only and is not legal or accounting advice. Communication
More informationHANDBOOK FOR PROVIDERS OF SCHOOL BASED/ LINKED HEALTH CENTER SERVICES
HANDBOOK FOR PROVIDERS OF SCHOOL BASED/ LINKED HEALTH CENTER SERVICES CHAPTER S-200 POLICY AND PROCEDURES FOR SCHOOL BASED/ LINKED HEALTH CENTERS Illinois Department of Healthcare and Family Services CHAPTER
More informationCompliance Considerations for Clinical Laboratories
Compliance Considerations for Clinical Laboratories Elizabeth Sullivan, Esq. McDonald Hopkins, LLC 600 Superior Ave., E, Suite 2100 Cleveland, Ohio 44114 P: 216.348.5401 / F: 216.348.5474 esullivan@mcdonaldhopkins.com
More informationMore than a Century of Legal Experience
Advanced Beneficiary Notice (ABN) and Hospital Issued Notice of Non Coverage(HINN): To Issue, or Not to Issue an ABN or HINN July 30, 2013 Presented by: Jennifer McManis More than a Century of Legal Experience
More informationReimbursement Policy. Subject: Consultations. Committee Approval Obtained: Section: Evaluation and 07/01/17. Effective Date:
Subject: Consultations https://providers.amerigroup.com Reimbursement Policy Effective Date: Committee Approval Obtained: Section: Evaluation and 07/01/17 06/06/16 Management *****The most current version
More informationDiabetes Outpatient Clinical Coverage Policy No: 1A-24 Self-Management Education Amended Date: October 1, Table of Contents
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1 General... 1 2.1.2 Specific... 2 2.2 Special
More informationPayment Policy: Problem Oriented Visits Billed with Preventative Visits
Payment Policy: Problem Oriented Visits Billed with Preventative Visits Reference Number: CC.PP.052 Product Types: ALL Effective Date: 11/1/2017 Last Review Date: Coding Implications Revision Log See Important
More information2018 No. 7: Radiology and Pathology/Laboratory Services
2018 No. 7: Radiology and Pathology/Laboratory Services POLICIES AND PROCEDURES Page 2 Table of Contents I. Diagnostic Radiology Policy... 3 II. Therapeutic Radiology Policy... 4 III. Pathology... 5 Page
More informationHospital Refresher Workshop. Presented by The Department of Social Services & HP Enterprise Services
Hospital Refresher Workshop Presented by The Department of Social Services & HP Enterprise Services 1 Training Topics Provider Bulletins Outpatient Claim Billing Changes Explanation of Benefit Codes Web
More informationThe Moving Target of Successful Long Term Care Therapy Reimbursement: Audits, Denials, and Appeals 8/13/2018 OBJECTIVES
The Moving Target of Successful Long Term Care Therapy Reimbursement: Audits, Denials, and Appeals Becky Finni, DHS, OTR/L Kim Karr, BS, OTR/L Senior Appeal Specialists for RehabCare OBJECTIVES Understand
More informationLaboratory Services Policy, Professional
Laboratory Services Policy, Professional UnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 Reimbursement Policy Policy Number Annual Approval Date 12/13/2017 Approved By Oversight Committee
More informationPrimary Ingredients. Primary Ingredients. Referrals. Positive cash-flow. Dedication & growth Give it some time and put effort into it
Establishing Community-Based Public Health and Screening Services Jeff Rochon, Pharm.D. Director of Pharmacy Care Services Washington State Pharmacy Association Primary Ingredients Establish the Interest
More informationOctober Hospice Fundamentals All Rights Reserved 1. ABNs: The Why, The What & The When. The Plan
ABNs: The Why, The What & The When Subscriber Webinar The Plan CMS Benefit Notices Initiative The Advance Beneficiary Notice of Noncoverage (ABN) The Uses: Statutory & Voluntary The Form The Difficulties
More informationTable of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness...
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Hospice... 1 1.1.2 Terminal illness... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1
More informationAmerican Health Information Management Association Standards of Ethical Coding
American Health Information Management Association Standards of Ethical Coding Introduction The Standards of Ethical Coding are based on the American Health Information Management Association's (AHIMA's)
More informationCHILD HEALTH SERVICES TARGETED CASE MANAGEMENT COVERAGE AND LIMITATIONS HANDBOOK
Florida Medicaid CHILD HEALTH SERVICES TARGETED CASE MANAGEMENT COVERAGE AND LIMITATIONS HANDBOOK Agency for Health Care Administration June 2012 UPDATE LOG CHILD HEALTH SERVICES TARGETED CASE MANAGEMENT
More informationDepartment: Corporate. Issued by: Kelley Roberson COO & CFO. Approved by:
Subject: Charity Care HAWAII HEALTH SYSTEMS C O R P O R A T I O N Touching Lives Everyday" Policies and Procedures Department: Corporate Issued by: Kelley Roberson COO & CFO Approved by: Policy No.: FIN
More informationEmerging Outpatient CDI Drivers and Technologies
7th Annual Association for Clinical Documentation Improvement Specialists Conference Emerging Outpatient CDI Drivers and Technologies Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA Outpatient Payment
More informationTutorial: Basic California State Laboratory Law
Tutorial: Basic California State Laboratory Law This document is meant to cover basic elements of state laboratory law and should not be relied upon in place of legal advice or the official codes of California.
More informationMEDICAID PRIOR AUTHORIZATION TRANSITION
MEDICAID PRIOR AUTHORIZATION TRANSITION Prepared for: Mississippi Medicaid Physicians and Providers Expanded EPSDT November 2013 December 1, 2013 The Road Ahead 2 Today s Goals and Objectives What stays
More informationHMSA Physical and Occupational Therapy Utilization Management Authorization Guide
HMSA Physical and Occupational Therapy Utilization Management Authorization Guide Published Landmark's provider materials are available online at www.landmarkhealthcare.com. The online Physical and Occupational
More informationTexas Medicaid. Provider Procedures Manual. Provider Handbooks. Telecommunication Services Handbook
Texas Medicaid Provider Procedures Manual Provider Handbooks December 2017 Telecommunication Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid
More informationALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-45 MATERNITY CARE PROGRAM TABLE OF CONTENTS
ALABAMA MEDICAID AGENCY ADMINISTRATIVE CODE CHAPTER 560-X-45 MATERNITY CARE PROGRAM TABLE OF CONTENTS 560-X-45-.01 560-X-45-.02 560-X-45-.03 560-X-45-.04 560-X-45-.05 560-X-45-.06 560-X-45-.07 560-X-45-.08
More informationSTATE OF CONNECTICUT
I. PURPOSE STATE OF CONNECTICUT MEMORANDUM OF UNDERSTANDING BETWEEN THE DEPARTMENT OF PUBLIC HEALTH AND THE DEPARTMENT OF SOCIAL SERVICES REGARDING DATA EXCHANGES Pursuant to section 19a-45a of the Connecticut
More informationReimbursement Policy (EXTERNAL)
Subject: Consultations Reimbursement Policy (EXTERNAL) Effective Date: 01/01/15 Committee Approval Obtained: 06/06/16 Section: E&M/Medicine ***** The most current version of our reimbursement policies
More informationState of Montana. Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES
State of Montana Department of Public Health and Human Services CHILDREN S MENTAL HEALTH BUREAU PROVIDER MANUAL AND CLINICAL GUIDELINES FOR UTILIZATION MANAGEMENT January 31, 2013 Children s Mental Health
More informationDATE: November 18, SUBJECT: Delegation of Personal Care Services Responsibilities
+-----------------------------------+ ADMINISTRATIVE DIRECTIVE TRANSMITTAL: 93 ADM-36 +-----------------------------------+ DIVISION: Health and TO: Commissioners of Long Term Care Social Services DATE:
More informationCHAPTER 13 SECTION 3.4 LABORATORY SERVICES
TRICARE/CHAMPUS POLICY MANUAL 6010.47-M DEC 1998 PAYMENTS POLICY CHAPTER 13 SECTION 3.4 Issue Date: August 26, 1985 Authority: 32 CFR 199.4(c)(2)(x) I. ISSUE How are laboratory services to be reimbursed?
More informationMississippi Medicaid Inpatient Services Provider Manual
Mississippi Medicaid Inpatient Services Provider Manual Effective Date: November 2015 Revised: June 2016 Inpatient Services Provider Manual Introduction eqhealth Solutions (eqhealth) is the Utilization
More information4. Program Regulations
Table of Contents LAB-35 iv 04/01/10 401.401: Introduction... 4-1 401.402: Definitions... 4-1 401.403: Eligible Members... 4-2 401.404: Provider Eligibility... 4-2 401.405: Laboratory Services Provided
More informationMedicare SELECT. Supplement Plans A, C, F & N. Plans C & N Outline of medicare supplement coverage
Medicare Supplement Plans A, C, F & N & SELECT Plans C & N 2011 Outline of medicare supplement coverage BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS Sold for Effective Dates on or After JANUARY 1, 2011
More informationINPATIENT Provider Utilization Review and Quality Assurance Manual. Short Term Acute Care
INPATIENT Provider Utilization Review and Quality Assurance Manual Short Term Acute Care Revised December 15, 2014 Table of Contents Section A: Overview... 2 General Information... 3 1. About eqhealth
More informationReimbursement for Anticoagulation Services
Journal of Thrombosis and Thrombolysis 12(1), 73 79, 2001. # 2002 Kluwer Academic Publishers, Manufactured in The Netherlands. Reimbursement for Anticoagulation Services Paul W. Radensky McDermott, Will
More informationA Unique Approach to Auditing the Primary Care Exception
A Unique Approach to Auditing the Primary Care Exception HCCA 2014 Compliance Institute San Diego March 31, 2014 Christine Anusbigian, MBA, CHC Specialist Leader, Health Sciences, Governance, Risk and
More informationA Unique Approach to Auditing the Primary Care Exception
A Unique Approach to Auditing the Primary Care Exception HCCA 2014 Compliance Institute San Diego March 31, 2014 Christine Anusbigian, MBA, CHC Specialist Leader, Health Sciences, Governance, Risk and
More informationGeneral Information. Overview. Purpose. Table of Contents
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.engage Inovalonto conduct outreach efforts for ouraca individual and small group on and off exchange
More informationImplementation Issues of the Physician Practice. for ICD-10-CM
Implementation Issues of the Physician Practice for ICD-10-CM What are ICD-10-CM and the Version 5010? The Centers for Medicare & Medicaid Services (CMS) is driving the industry to upgrade core HIPAA transactions
More informationApril Hospice Fundamentals All Rights Reserved 1. The Certification/ Recertification Process: No Room for Error. What You Will Learn Today
The Certification/ Recertification Process: No Room for Error Subscriber Webinar What You Will Learn Today Regulatory requirements Election of the Medicare Hospice Benefit Certification Recertification
More informationTO BE RESCINDED Fee-for-service ambulatory health care clinics (AHCCs): end-stage renal disease (ESRD) dialysis clinics.
ACTION: Revised DATE: 03/13/2017 1:25 PM TO BE RESCINDED 5160-13-01.9 Fee-for-service ambulatory health care clinics (AHCCs): end-stage renal disease (ESRD) dialysis clinics. Requirements outlined in rule
More informationKing County Regional Support Network
Appendix 1 King County Regional Support Network External Quality Review Report Division of Behavioral Health and Recovery January 2016 Qualis Health prepared this report under contract with the Washington
More informationTELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL
TELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 TELECOMMUNICATION SERVICES Table of Contents 38.1 Enrollment......................................................................
More information* NEW PROCESS FOR ADVISING MEDICARE ADVANTAGE MEMBERS OF THEIR RIGHTS AS INPATIENTS AND AT DISCHARGE *
* NEW PROCESS FOR ADVISING MEDICARE ADVANTAGE MEMBERS OF THEIR RIGHTS AS INPATIENTS AND AT DISCHARGE * JUNE 22, 2007 MSFB-HOSP-2007-004 TO: FROM: (1) CHIEF EXECUTIVE OFFICER (2) CHIEF FINANCIAL OFFICER
More informationHome Health, Hospice, and Nursing Facility. Indiana Health Coverage Programs DXC Technology October 2017
Home Health, Hospice, and Nursing Facility Indiana Health Coverage Programs DXC Technology October 2017 Agenda Billing Tips Home Health Hospice Nursing Facility Claim Form Update Helpful Tools Questions
More informationDiagnosis Code Requirements - Invalid As Primary
Manual: Policy Title: Reimbursement Policy Diagnosis Code Requirements - Invalid As Primary Section: Administrative Subsection: Diagnosis Codes Date of Origin: 1/1/2000 Policy Number: RPM054 Last Updated:
More informationPolicy Subject Index Number Section Subsection Category Contact Last Revised References Applicable To Detail MISSION STATEMENT: OVERVIEW:
Subject Objectives and Organization Pathology and Laboratory Medicine Index Number Lab-0175 Section Laboratory Subsection General Category Departmental Contact Ekern, Nancy L Last Revised 10/25/2016 References
More informationHow to Request Laboratory Services
Jump to: Requests for Priority (STAT) Services Tests Not Listed in Catalog VCUHS: General Lab Manual (Downtime) Request (Internal Use Only) VCUHS Outreach Client: General Lab Request Anatomic Pathology
More informationPURPOSE: This policy provides an overview of SHANDS Jacksonville Laboratory s commitment to the care and safety of the patients we serve.
PAGE 1 of 5 TITLE: Provision of Care Regarding Laboratory Services PURPOSE: This policy provides an overview of SHANDS Jacksonville Laboratory s commitment to the care and safety of the patients we serve.
More informationChapter 11 Section 4. Hospice Reimbursement - Guidelines For Payment Of Designated Levels Of Care
Hospice Chapter 11 Section 4 Hospice Reimbursement - Guidelines For Payment Of Designated Levels Of Care Issue Date: February 6, 1995 Authority: 32 CFR 199.14(g) Revision: C-6, October 20, 2017 1.0 APPLICABILITY
More informationGOVERNMENT OF THE RUSSIAN FEDERATION. DECREE of December 27, 2012 N On the Rules STATE REGISTRATION OF MEDICAL PRODUCTS
GOVERNMENT OF THE RUSSIAN FEDERATION DECREE of December 27, 2012 N 1416 On the Rules STATE REGISTRATION OF MEDICAL PRODUCTS In accordance with Article 38 of the Federal Law "On the basis of health protection
More informationProvider Handbooks. Telecommunication Services Handbook
Provider Handbooks December 2016 Telecommunication Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health
More information