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A superior coder’s expertise is vital to navigate coding guidelines, commercial payer rules, and federal regulations.  The coder must also apply compliance knowledge to scrutinize the medical documentation to fully and accurately report the services provided.

Two of Medicare’s pre-payment review programs are NCCI and MUE.  NCCI is a set of correct coding edits designed to detect inappropriate code pairs, often referred to as unbundling.  These edits are incorporated in their claim processing system as automated edits testing every code pair reported for the same date of service, same patient, by the same provider against the edit tables.  If a code pair fails an edit, Medicare’s system will deny the column two code unless NCCI allows an appropriate modifier and such modifier was reported.  MUE, or Medically unlikely edits, are also automated system edits intended to avert inappropriate payments based on CMS established maximum units of service for some CPT and HCPCS codes.  A code that does not pass MUE edit review will be denied.

CERT and RAC are post-payment review programs.  The CERT contractor selects random small samples of Medicare claims and compares them with provider/supplier medical records to detect Medicare payment errors based on coverage policy, correct coding and billing.  This process results in a determination of national Medicare error rates such as, Paid Claims Error Rate and Provider Compliance Error Rate.  CMS allows RACs to analyze paid claims as far back as three years, utilizing proprietary software, for improper payments.  If improper payments are identified a file is forwarded to the Medicare contractor to adjust the claims and recoup payments from the providers.  Medical records are requested from the provider in the event the RAC detects likely improper payment(s) and may also result in recoupment of payment to providers.

With such intense scrutiny of provider claims and documentation, expert coding and compliance must be a part of daily revenue cycle operations to reduce a provider’s probability of returning payments and to aid in containing billing costs related to appeals.

Let’s first define successful billing.  In the age of Medicare’s pre-payment and post-payment claim review programs such as, National Correct Coding Initiative (NCCI), Comprehensive Error Rate Testing (CERT), Medically Unlikely Edits (MUE), Recovery Audit Contractor (RAC), and Medical Review, success in medical billing means more than receiving prompt and accurate payment for services rendered.  It also means KEEPING those payments, in combination with controlling billing operations costs.

PhyBus, LLC’s Reimbursement Team stands ready with Certified Professional Coders (CPC) to provide expert coding services for our clients..