Week 8 Lecture Notes: Business of Medicine, HIPAA, Medicare, and More

Introduction

• Lecturer: Mrs. J
• Topics: Medicare, HIPAA, SOAP, OIG, Fraud and Abuse

Key Trademarks and Credentials

• AMA: CPT 2023
• AAPC: CPC, CRC, COC, CPMA, CPB, CPPM, CPCO
• AHIMA: CCA, CCS, CCSP

Medicare Overview

• Parts of Medicare: A, B, C, D
  • Part A: Inpatient hospital care, Hospice, Home Health, etc.
  • Part B: Outpatient care, not covered by Part A
  • Part C: Medicare Advantage (combines A and B, sometimes D)
  • Part D: Prescription drugs
• Administration: CMS (Centers for Medicare and Medicaid Services)
• Largest payer: Government (Medicare, Medicaid, Tricare)
• CMS: Established 1965, regulates icd-10-cm and PCS coding

HIPAA Overview

• Full Name: Health Insurance Portability and Accountability Act of 1996
• Five Titles:
  • Title I: Health insurance protection for workers
  • Title II: Administrative Simplification (focus for coders)
  • Title III-IV: Guidelines for tax and health plans
• Key Terms:
  • PHI (Protected Health Information): Any info linking patient to health status
  • Covered Entities: TAP (Treatment, Administration, Payers)
  • Minimum Necessary Rule: Only share minimum necessary PHI

SOAP Note

• S: Subjective - Patient's statements
• O: Objective - Doctor's observations
• A: Assessment - Doctor's diagnosis
• P: Plan - Treatment and plan of action

OIG Compliance and Fraud

• OIG: Office of Inspector General
  • Focus: Fraud and Abuse investigations
  • Compliance Plans Required: Internal monitoring, Compliance Standards, Training
• Work Plans: Published twice a year (e.g., Remote Patient Monitoring)
• Fraud vs. Abuse:
  • Fraud: Knowing and willful false representation
  • Abuse: Practices leading to unnecessary costs

Medical Necessity

• Definition: Services reasonable and necessary for diagnosis or treatment
• Coverage Review: Medicare Coverage Database (McD)
  • NCDs: National Coverage Determinations (applies nationwide)
  • LCDs: Local Coverage Determinations (applies regionally)
  • If neither covered, submit pre-determination request

Scenarios:

1. Prostatectomy: Necessary for prostate cancer
2. Tonsillectomy: Necessary for tonsillitis
3. Discectomy: Necessary for disc herniation
4. Hysterectomy: Necessary for fibroid uterus

Advanced Beneficiary Notice (ABN)

• Purpose: Inform patients of non-covered services
• When Required: Before a service exceeding $100
• Form: H-I-N-N for facilities

Fraud and Abuse Examples

1. Billing higher rates for Medicare: Fraud
2. Incorrect billing due to repeated patient calls: Abuse
3. Submitting claims for non-covered Botox: Abuse

Final Thoughts

• Review Questions:
  • ABN: Advance Beneficiary Notice
  • HIPAA: Health Insurance Portability and Accountability Act
  • PHI: Protected Health Information
  • Minimum Necessary Rule: Applies to covered entities

Conclusion:

• Moving to Part Two with a focus on advanced coding practices
• Appreciation for the team and interns

[Music]