Evaluating Compliance Strategies
HCR/220
January 3, 2011
Fonzette Mixon

Evaluating Compliance Strategies
The compliance process is set up to ensure the maximum appropriate reimbursement for health care claims. Correct billing and coding are directly linked to correct documentation by a physician. Also, to complete documentation, linking the correct code to the correct diagnoses is a must. This step is vitally important in reducing compliance errors. Second, the implications of incorrect coding can have a domino effect and will ultimately cause many people in the chain of events to go back, review, correct the errors, and resubmit the claim. This could also cause the patient and payer more money or cause a claim to be denied.
Another strategy designed to help coders maintain compliance is to provide employees with job reference aids. A job reference aid is similar to a cheat sheet in the sense that it is a quick reference for the most commonly used CPT codes in that particular practice. If aids are used, it is important that they are dated and current. They should also be updated every year as new codes and updates are released. Also, all CPT E/M codes must contain all the codes in that range. The final strategy would be to do self audits to monitor billing and coding compliance. Establishing a system for monitoring the billing process and performing regular compliance checks is a great way to ensure adherence to established policies and procedures. External audits include private payers or government investigators to review selected records for compliance. Internal audits are done individually and voluntarily within a practice to reduce errors and show compliance (Valerius et al, 2008).
The next major subject in coding compliance is correctly linking the procedure to the diagnoses. Diagnoses and procedures must be correctly linked on healthcare claims for which payers use this information directly to determine the medical necessity of the charges. All codes should be appropriately documented which ties into complete documentation done at the time of the procedure. If the initial documentation is not done adequately, then a domino effect of incorrect