Learning Outcomes
After studying this chapter, you should be able to:
Explain the importance of properly linking diagnoses and procedures on health care claims. |
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Describe the use and format of Medicare’s Correct Coding Initiative (CCI) edits. |
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Discuss types of coding and billing errors. |
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Explain major strategies that help ensure compliant billing. |
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Discuss the use of audit tools to verify code selection. |
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Describe the fee schedules that physicians create for their services. |
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Compare the usual, customary, and reasonable (UCR) and the resource-based relative value scale (RBRVS) methods of determining the fees that insurance carriers pay for providers’ services. |
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Describe the steps used to calculate RBRVS payments under the Medicare Fee Schedule. |
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Identify the three methods most payers use to pay physicians. |
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Discuss the calculation of payments for participating and nonparticipating providers, and describe how balance billing regulations affect the charges that are due from patients. |