I want to make you familiar specifically with Medicare and the parts of Medicare HIPAA and what is HIPAA what is Phi what are the covered entities and minimum necessary we are also going to talk about soap what is soap and for the first time I'm going to have a discussion with you about mcds specifically LCDs and ncds also we're going to talk about the oig the oig compliance and work plans and we're going to end things with Fraud and Abuse all right these sound like boring subjects so I'm gonna do my best to make them interesting oh and by the way all of these subjects are our goals of the discussion now let's talk about key business of medicine terms so you should know what these are you should know what a professional coder is I don't think I need to Define that well just in case professional coders are coders who code for professionals yeah they code for doctors qualified Health Care practitioners Etc and they also code for durable medical equipment yeah that's pretty much them and often they get their CPC facility coders code for the facilities they code for outpatient facilities and inpatient facilities so that means if they're not coding for the professionals they're coding for that facility in all things owned by that facility and provider provider is anyone or an entity that renders Medical Care Service or supplies these are providers so a doctor is a provider right yeah we all know doctors or providers did you know there are two types of doctors medical doctors not medical doctors but there are two types of Physicians Physicians go ahead type in the chat did you know and if you do write the different types of doctor the two different types wow we're kind of I didn't phrase that right because the chat is shh you're quiet it's okay let's get into it all right so we have DOS and MDS these are the two type of Physicians that um professional coders code for right and in the middle let's focus in the middle this is what they have in common they both prescribe medications they both um write orders and do follow-up testing they both work in various Medical Specialties and they both are fully licensed and eligible for board certification and these are both Physicians however if you look to the left a do is a doctor of osteopathy in other words they have a more holistic approach they prefer holistic medicine versus drugs okay or allopathic medicine um and they attend Medical School an osteopathic medical school and they really believe that diseases can be managed or cured I want to say this I don't like to say things generally so they typically let's say typically believe that the spine and proper alignment of the spine is directly correlated to a healthier body I like that now we get on over to the MDS they believe in treating symptoms right symptom resolution approach they adhere to allopathy that means they prescribe medications and they attend allopathic medical schools but nonetheless they are both Physicians and they both can use or or yeah use the CPT codes in your CPT manual they can assign CPT codes right we know that because they're Physicians also we know that qualified Health Care practitioners can utilize those CPT codes these two are providers and types of qualified Healthcare practitioners or the most common you'll see are new nurse practitioners and or physician assistants yeah these are physician extenders and they are what we call qhps qualified Health Care Professionals here are the similarities on the left both are licensed health care providers who can work alongside Physicians both can diagnose and treat illnesses as well as prescribed medications both can require both require a graduate degree clinical training and board certifications yeah and on the right here are the differences nurse practitioners attend a graduate nursing program physician assistance attend a master's program based on medical education nurse practitioners have full practice Authority in 27 States physicians assistant work interdependently with Physicians and nurse practitioners have specialty Fields Pas have more generalized medical education so nonetheless both are physician extenders or qualified Health Care Professionals you're going to hear that a lot when you get to part three all right now let me tell you about the hierarchy I think you know this but if you didn't Physicians are at the highest level of medical decision making whether you're an MD or a do you're at the exact same status then you have what we call the mid-level providers or qhps those are your nurse practitioners they require master's degree physician's assistant typically attend a 26 and a half month program and these are both physician extenders now that we've learned briefly about providers let's talk about payers all right so maybe I should have asked you before I moved on how are you doing are you okay with those providers do you understand the difference outstanding outstanding all right so now let's talk about payers what is a payer a payer is an agency or company that pays medical bills right yeah well who would do that well you're going to see in a moment um payers basically reimburse providers or the beneficiaries for their services so a beneficiary beneficiary Airy is someone who is covered under a plan all right now can you tell me who the largest payer is the largest payer of medical expenses is in the U.S go ahead type in the chat no answer is wrong I want to know just yeah yes yes yes let me tell you who it is you all are saying it it's the government yes they are the largest payer they have when you think about you think about Medicare you think about Medicaid and Tricare if you didn't know Tricare is military yeah we've got a lot of military um beneficiaries all right and if you didn't know Medicare is for our seniors and Medicaid is for the people who cannot afford health insurance and of course some of you were naming the other payers we have private insurers or third-party payers I saw United Healthcare come through the chat Blue Cross Blue Shield hmos ppos POS I and I can just go on ncos oh goodness well just so you know of the private payers United Healthcare has taken over and they have become the largest private payer yeah they've beat out Blue Cross Blue Shield did you ever think all right so now that we know what a pair is and the largest payer is the government I want to talk about that largest payer right I want to talk about Medicare Medicaid and Medicare Medicaid is administered through the centers for Medicare and Medicaid services or c m s right and I'm gonna tell you CMS is a big and very very powerful entity in health care even though this is the government and the government is the largest payer they have a lot of power and when you think about it anyone who has who's the largest payer they're going to have a lot of power so let me tell you about them first and then I'm going to tell you why they have so much power CMS was established in 1965 for seniors and the original name was Health Care financing Administration and I know this company as hikvah that's what we called it back in the day but today it's CMS so in 1965 they developed into this very large entity and they regulate the payments for Medicare and Medicaid then in 1977 they changed their name to CMS and they also included chip and that's for children as well as HIPAA HIPAA became integrated in a lot of their doings and HIPAA um came about in 1965 as well but since it's an Inception CMS played a crucial role role in administration and oversight of Medicare and Medicaid and they came up with lots of rules and these rules were assigned to Providers and they say hey if you want to see our if you want to get paid by us you have to do the following things and and providers jump through hoops to do them so that they can get paid and these hoops are kind of rigorous so providers kind of and other payers kind of follow suit they kind of do what CMS does for everybody if it makes sense sometimes payers come up with their own policies but CMS they regulate and if you didn't know CMS regulates icd-10-cm that's the diagnoses they are one of the four cooperating parties responsible for icd-10-cm CMS regulates PCS coding yeah I know you all may not know about that but when you get higher up and you go into part five you're going to learn about PCS coding so they are very powerful all right I may have digressed but I'm back now we know that Medicare is medical coverage for patients 65 years of age or older for the blind the disabled individuals and people with permanent kidney failure or end-stage renal disease and Medicare is funded by the federal government whereas Medicaid is a jointly funded program in other words it's funded by both the federal government and the respective state governments so it's joint funding and it covers children um needy or Indigent people blind disabled Etc and that's who they are and they are regulated by CMS now that you know what Medicare and Medicaid is and CMS is let's talk about medicares we're ready for an adult conversation about medicares not like last week but we can speak a little more fluid about them so many of you probably heard about Medicare part A Medical Care part A helps cover inpatient hospital care such as nursing facilities Hospice Care Home Health and inpatient when the patient is confined to the hospital Medicare Part B helps cover outpatient care and things not covered under Medicare part A right part C this is also called Medicare Advantage so it combines the benefits of part A and B and sometimes D we're going to talk about that the plans are managed by private insurers approved by Medicare and they may include ppos or hmos in part D this is the prescription drug so inpatient hospital is part A Part B outpatient and things not covered under Medicare part A and just know Medicare Part B is not inpatient part C is Medicare Advantage and how can I explain that I do want to let you know that um part C if you notice those commercials that are offering Medicare part C plans I don't know if you see them I see them a lot but maybe because um I'm getting ready to be Medicare age or I do a lot for my mother who is Medicare age and what they are trying to do they're trying to get my mother to give up her private part [Music] um my mother has regular part A and regular Part B and they want her to get a Medicare Advantage plan like a PPO for her Medicare so that they can manage it they want her to have a Managed Medicare because they spend the government spends way more money giving her straight part A and Part B services but my mother will not give it up and I don't blame her that is the best when you get Managed Care it is managed so you don't have the flexibility and they also give you all kinds of incentives to take advantage of this Managed Care well we'll give you groceries for a year we'll pay for your working out at the gym they have all kinds of incentives because it does make fiscal sense to have part C but that's what that is that is a managed care for Medicare that's part C in part D we know that is prescription drugs so here's a simplified look all right so we we already said part A is Hospital Part B is outpatient and professionals part C Managed Care Part D prescription drugs and if you put them all side by side it looks like this so these are your Medicare coverages at a glance and on that note I want to take a look in the chat to see if you understand what part A Part B part C and Part D are and if you don't type in the chat let me know okay I got a few yeses if you don't say hey I don't understand this and I understand we have we have quite a few International students and they may not be able to perceive our health insurance and I get it so if you need more clarification I am here right someone said they understand too well I know what you mean all right so now I want to shift gears and I want to talk about HIPAA right HIPAA a lot of people hear about HIPAA this is my HIPAA violation HIPAA hit the hippo what is HIPAA well HIPAA is the acronym for the health insurance portability and accountability Act of 1996. HIPAA today provides Federal protections for personal health information when held by covered entities now when HIPAA started in 1996 it didn't have anything to do with that HIPAA if you think about the acronym health insurance portability and accountability Act HIPAA came about because people who had jobs could not carry their insurance with them their insurance was not portable like a portable radio you carry it the young people may not know what I'm talking about but the older people may their insurance wasn't portable once you left your job you lost your insurance or they had these exclusions these 90 days patients typically had well excuse me employees had to wait 90 days before their insurance kicked in can you imagine if you had a chronic illness and you had to wait 90 days to get a prescription of let's say high blood pressure medicine that would be disastrous so that's why HIPAA came into being now today HIPAA this is on protecting a patient's personal health information e h i personal health information protected health information and that largely has come about well the the change has come about largely due to the internet and hackers and all of the mischievous things that people do with people's data so that's why HIPAA is what it is today and today a key provision of HIPAA is safeguarding the patient's health information and that's what providers have to do and the people responsible and bound under HIPAA they're actually covered entities so everyone is not not um everyone does not have to adhere to HIPAA but those covered entities they have to indeed now today HIPAA has five titles Title One this protects health insurance for workers and their family and also they have pre-existing conditions they can still have coverage this is the original title of HIPAA also titled two title two is Administrative simplification and these were established as a result of the internet and the movement to protect patients information and then you've got title three these are guidelines for pre-taxed medical spending accounts title IV sets guidelines for Group Health Plans title four five well four five governs company owned life insurance policies but when it comes to HIPAA and us as a coder it is title two that we have to be familiar Title II of HIPAA known as the administrative simplification a s Provisions requires the establishment of national standards for electronic health care transactions and National identifiers for providers health insurance plans and employers also establishes privacy rules so HIPAA they got a lot of regulations packed in that little paragraph now at coders are focused is protected health information but what is t-h-i or personal health information p-h-i is used interchangeably for protected health information or personal health information so what exactly is it what is personal health what is the personal health information that we are protecting in healthcare anybody know what we're protecting indeed somebody said medical records in identifiable patient information I love it but let me break it down just a little more anything that links the patient to his health status anything I said in health care okay anything that that links the patient to their health status that needs to be protected now these are some of the things that has to happen to protect a patient's Health Care these are some of the things that are implemented in in practices at the onset of an encounter a patient must receive a notice of privacy practices right so every time you go to the doctor they tell you um sign this and say you've read it sign this and say that you have it they always do that I'm like oh my goodness may I have it so I always ask them for that notice give it to me so I'm not telling an untruth but nonetheless when you get that patient privacy and protected Health form this is what it says if you've ever read it it says they tell you the ways that the patient's Phi may be used and disclosed they also let you know their Duty as a provider to protect your Phi they also tell you that if you feel that your Phi has been violated you have the right to complain to Health and Human Services and a point of contact for further information and complaints that's what should be on there and finally specific distribution requirements for providers and plans so they're talking about distribution of your Phi also under the Privacy Rule the HIPAA Privacy Rule and this speaks to the last point that I was making the distribution requirements for providers and plans well if you didn't know the distribution requirement minimum necessary right minimum necessary if a payer needs the patient's operative report to pay to establish medical necessity to pay for a procedure being carried out that office should not send the whole record just the minimum necessary just send the operative report all right and that's pretty much it now I did say that everyone is not bound to HIPAA it is those that are referred to as covered entities covered entities are bound under HIPAA in health care and what is a covered entity well I like to call them tap yeah tap right those that are responsible for the treatment of the patient and their staff doctors clinics psychologists dentists chiropractors nursing homes pharmacies you name it those responsible for treating that patient and their staff that's your t for treatment in tap your Clearing House the Clearinghouse and their staff these are the people who are responsible for the administration of the business these this is where we fall this is where your coders and your billers fall also these include entities that process non-standard health information they receive from another entity into a standard format right because HIPAA requires this standard format for um claims to be processed and these Healthcare Clearing Houses do that and if a coder or a biller works for a health care provider they may carry out the coding and the billing services but that once they're finished it gets sent over to the Clearinghouse for them to administrate or administer the business and finally your health plan your health plans these are the payers right all the health insurances your hmos the government programs Medicare Medicaid everyone these are the payers and this rounds out your tap and remember tap represent your covered entities and their staff now before I move on I want to know how you're doing are you with me foreign good deal I want at least half of the class to respond I don't want to be one of those instructors that look at three answers and say oh good no at least half of you good job so you're all with me now if a provider or covered entity fails to uphold HIPAA there is a consequence you can file a claim through the office of civil rights if at any time your Phi has been violated or anyone's they can file a claim through the office of civil rights and just so you know there are two oversights agencies oversight agencies you have the office of civil rights they're responsible for enforcement of patient privacy you also have the office of Inspector General and their primary focus Fraud and Abuse in health care and we're only talking about in-health care all right so let me quickly just tell you a little bit about the office of civil rights this is under the Health and Human Services HSS and so too is CMS right and they enforce Federal and civil laws and HIPAA so they also encourage teaching Health and Social Service workers about civil rights laws they endorse and espouse education in communities and they also they investigate civil rights cases now when it comes to the office of Inspector General in health care this too is a government tasks agency and we're going to talk more about it but nonetheless their focus in health care is to investigate Fraud and Abuse and I'm going to leave OCR and oig and now I'ma turn our attention to medical necessity and the reason medical necessity is directly related to Fraud and Abuse it's directly related because doctors have to substantiate medical necessity before they can carry out anything before they can carry out a procedure yeah they have to the the federal government mandates that all procedures be medical necessary before it's paid and when we say Federal we're talking about Medicare and when Medicare what Medicare does often others do the same they follow suit so what is medical necessity well Medicare defines medical necessity as services or items reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member to put it simply your diagnosis or you must have a diagnosis to justify every procedure or service yes you have to have a diagnosis to justify a procedure but not just any diagnosis a specific diagnosis right yeah I have an exercise and I want to see if you understand what I'm talking about so this is called link the procedure to the diagnosis to determine or substantiate medical necessity right so if Medicare says that you need a diagnosis before you can carry out this procedure what is that diagnosis all right so we've got prostatectomy on the left on the right are a list of diagnoses of the following which diagnosis will substantiate medical necessity will it be conjunctivitis pilonidal cyst fibroid uterus tonsillitis diabetes mellitus prostate cancer disc herniation go ahead type your answers in the chat and you all were raining through that chat at least three of you outstanding good job 100 of you got it right so far go ahead give it a try good job we have I don't think half of the classes answered come on take a take a um guess and don't worry that I said 100 of them got it correct it's okay it's all right you're safe here I promise I will never say your name all right so if you said prostate cancer absolutely because prostate cancer substantiates medical necessity for a patient to have a prostatectomy right you're going to remove the prostate you better have prostate cancer or something like that all right what about tonsillectomy what is the diagnosis that will substantiate is a conjunctivitis pilonidal cyst fibroid uterus tonsillitis diabetes mellitus or disc herniation go ahead type your answers in the chat good deal very very good you said tonsillitis outstanding all right what about a cervical discectomy not cervical I'm telling my I'm telling myself what about discoctomy go ahead put your answers in the chat good job good job and the answer is disc herniation and finally hysterectomy what say you of the remaining which diagnosis will substantiate medical necessity for a hysterectomy all right they're coming in there coming in coming in absolutely fibroid uterus will substantiate medical necessity outstanding so you got the picture right so Medicare says hey if you want us to pay for these procedures the diagnosis must justify that procedure now did you all ever think about how providers come up with a diagnosis let alone establish medical necessity how do they do it well maybe you haven't thought about it but I did yeah so I'm going to tell you how they do it doctors determine medical necessity based on the following when a patient comes to see them doctors will document a soap s-o-a-p and soap is the acronym for subjective objective assessment and plan so their documentation must have a soap and you may say what is a subjective well the subjective is what the patient says to The Physician so everything the patient says about their condition so it's the patient statement about his or her health and the patient explains all of the symptoms um the timing the intensity Etc this is the patient's version not the doctor now the doctor May prompt the patient by saying what brings you here today and the patient will say I had a fever and sore throat for the parents three days all right in the real world subjective is something that is not proven it's basically an opinion right it's subjective it's debatable it's not fact and you see why it's not fact the patient said they're having a heart attack right now what is fact the doctors right well in medicine what the doctor observes sees feels is documented and it is fact right the provider examines the patient and they document their findings that's a fact in medicine then after the subjective and objective the doctor does their work the doctor will evaluate all of the data and make a conclusion in that conclusion is the doctor's diagnoses and that diagnosis that's a fact and finally the plan the plan is what the doctor is going to do to treat that illness his course of action and treatment plan this is how we're going to fix it repair it or cure it so that is a soap soap is the acronym for subjective objective assessment and plan and this is what the provider documents in the assessment the assessment is what establishes medical necessity because we said this the diagnosis is in the assessment right so that's how doctors establish medical necessity now how do we know if something's medically necessary the doctor can document it but how do we know if it's medically necessary right so the doctor can can in their right establish medical necessity but how do we know that Medicare says it's medically necessary and that they're going to pay for it well we know the typical things will be paid like the prostatectomy if you have prostate cancer like the hysterectomy if you have uterine cancer um your time you know tonsillectomy if you have tonsillitis we know that that's almost standard but what about those decisions that aren't so cut and dry we know how do doctors know if something's going to be paid or not how do they know if it's medically necessary well Medicare has something Medicare has what they call coverage databases and you use these databases when the diagnoses may not justify the procedure or when you're not sure if the diagnosis will justify the procedure right and these databases are called well there's one major Hub called The National coverage um excuse me Medicare coverage database right that's where you go you go to the McD and in the McD you'll find the national coverage determinations and the local coverage determinations right so National the difference between the two National coverage determinations are coding guidelines released by CMS coding and coverage guidelines and these guidelines apply Nationwide look at this end to U.S terrorists we're going to say territories there you go all right apply Nationwide and to U.S territories whereas the local coverage determinations these are coding and coverage guidance released by Medicare contractors or people contracted by Medicare and we call them Max Medicare administrative contractor and their guidelines apply to the contractors region or jurisdiction you see the little map below just want to let you know that and these local coverage determinations the LCDs should not contradict an NCD I'm gonna let that marinate so ncds are national coverage determinations LCDs local Medicare releases the guidelines for ncds for the nation and U.S territories and the jurisdictions or the max or the Medicare administrative contractors they provide the guidance or guidelines for the local jurisdictions and they should not contradict the national and you see the little map let's make it a little bigger these Max divide up the nation they're divided and this is who has jurisdiction in terms of the coverage or makes the decisions about medical necessity so I'm in Pennsylvania so the person that I reach out to will be novitas and they will make determinations on the behalf of my clients in the state of Pennsylvania if there are no National coverage determinations okay we're going to get into the particular but what's important is you need to know that these are your Medicare administrative contractors they are contracted by CMS to provide coverage determinations to provide um support and guidance in terms of what is covered and what is not and they also make rulings in terms of what is covered and what is not now that you're looking at this map type in the chat tell me who's your Mac what is your jurisdiction type it in the chat good job and based on people saying what their jurisdiction is I know somewhere around where you live someone said Palmetto Palmetto and without even looking at this because I used to live in North Carolina I said okay you might be Georgia North Carolina South Carolina indeed so don't say the state write down your jurisdiction and when you take your exam you just may have a question when they say jurisdiction jurisdiction is talking about local coverage determinations now take a look at that database that I talked about I talked about that Medicare MCD Medicare coverage database and it looks like this yes CMS administers it and this is a whole database about coverages now how do we use it well we use it to access the ncds and the LCDs right so I'm just going to walk you through a scenario not scenarios like we usually have but a scenario so this patient desires sterilization but she wants a hysterectomy she said hey I don't want to deal with none of that monthly stuff just give me a hysterectomy let me get it over with so Dr Kim says it doesn't sound like it's going to get paid so I need to determine if this hysterectomy will be medically necessary so Dr Kim does the following she logs on to the CMS McD she looks first for the national coverage determination and if there's no National coverage determination she looks for the LCD so let's go ahead and walk it through this is what Dr Kim did she typed in hysterectomy she placed her state then she pressed enter and boom hmm I think I'm a little backwards she shouldn't have come here first give me a moment how did this happen all right so she typed in hysterectomy and said boom here you go so sterilization comes up and she reads this is the publication the manual the manual title the version number and she continues here's the description one moment there you go all right here's a description and then she sees sterilization and she clicks on it because it's an NCD this is a national coverage determination this is good so she clicks on it and here is the description a while sterilizations at the top and then you come down and you see indications and limitations of coverage Aces nationally coverage conditions okay says nationally covered conditions and then B says nationally non-covered conditions and it says elective hysterectomy tubal ligation and vasectomy if the primary indication for these Services is sterilization so it means that these are non-covered conditions a sterilization is that is performed because of physician believes another pregnancy would endanger the overall health of the woman is not considered to be reasonable and necessary whoa whoa whoa okay okay so this is the guidance they're not covered so the NCD said the hysterectomy will not be paid if for sterilization you gotta try something else do you all understand how this NCD is sort of working if you want to wait before you pass judgment that's okay because we have more alright so we know this sterilization is not going to be paid if that is the diagnosis used to substantiate a hysterectomy so now we have another scenario a patient has a provisional Tech disorder and Dr Kim would like to administer botulinum toxins or Botox treatments and if you didn't know a provisional tick is a sudden and brief repetitive movement or vocalization that is experienced by individuals with tick disorders I don't know if you see people with tick disorders day to day but I see them a lot on social media and I think um I've learned a lot about it so I understand that there are some treatment methods for them but we're going to find out if Botox treatments will be medically necessary and for provisional texts what do you think type in the chat do you think that Botox will be um provisional ticks will substantiate medical necessity for Botox treatments type in the chat um well we'll see we'll see you know what let's see well just so you know Dr Kim is going to log on to cmsmcd she's going to look first for the NCD the national coverage determination if there's no NCD she'll look for the local coverage determination for her jurisdiction all right so she's going to log in she's going to type in Botox injections she's going to type in her State and hopefully this works boom okay well all the options she has there are several LCDs no ncds so that is fine she's going to find her jurisdiction so let's say she's in Pennsylvania with me so novitas is her jurisdiction so they all are botulinium toxins and this is an LCD for botulinium toxins for the Mac novitas Solutions all right so our Mac is novitas so we're going to click on it and what does it say all right so we know we're at the correct Place botulinium toxins and then I'm going to look down and it says botulinium toxins Botox dysport xenomine and bioblock wow will be considered medically necessary and reasonable when administered for treatment of FDA labeled indications and off-labeled indications as applicable below so let me read further all right so here are the things they'll cover esophageal Asia chronic and fissure for patients with inadequate response to conservative pharmacological treatment oh excuse me this is chronic anal fissure sorry about that essential hand tremor for patients with a high altitude Tremor that disrupts activities of daily living and have inadequate response to oral pharmacology pharmacotherapy such as Propranolol and primidone focal limb dystonia hemifocal spasm in or hemifacial spasm in adults cranial nerve VII disorder isolated oromandibular dystonia in adults laryngeal dystonia dysphonia for abductor type bothersome simple motor ticks in adolescence and adults with the benefits of treatment outweighing the wrists all right so we do have these motor tics they will be covered so the Botox injections will be paid for provisional ticks all right so now how are you feeling okay so we're understanding a little more okay I got one more we're going to go in and we're going to see Dr Kim here's a patient here she says hey I had a breast reduction last year but I'm not pleased with the appearance the breasts are still sagging and the patient desires a breast lift or a mastopexy Dr Kim says I don't know if that masto pexy will be medically necessary but I'm going to check so she logs into the McD and she types in mastopexy types in her state and search and under the Cosmetic and reconstructive surgery she keeps going she doesn't see anything about a breast lift but right here I don't know if you can see it but right here 19316 this is the CPT code for mastopexy all right so she's got to do her work because there are tons of icd-10-cm codes you've got all these we know this is breast cancer the C50 yeah we know that's cancer and we're looking through all of the Cancers and then we start seeing some different diagnoses still some um labular carcinoma intraductal carcinoma we see that but we get down and we look at everything and there's still carcinoma however when you get here you see an n6 5.0 this is the deformity of reconstructed breasts hmm and then you have n6 5.1 disproportion of reconstructed breast I don't know but if you keep going you see breakdown of breast prosthesis and such leakage Etc and then you see um this a breakdown of the breast implant Etc and then breast implant status Etc but it seems like these two may fall or they may not because it depends on what the payers Define reconstruction as and I'm I don't think this a breast reduction is defined as reconstruction but it could be so Dr Kim is going to be like well I don't know it may or may not so Dr Kim has the option to submit a predetermination into the insurance carrier and the insurance carrier will let you know definitively if they'll pay for it so to sum things up when it comes to Medicare coverage database or the McD to determine medical necessity first you're going to look in the NCD second the LCD and third we didn't even say that if there is no LCD you just reach out to the Medicare administrative contractor in the appropriate jurisdiction and ask them to make a determination yes it's that it that's the protocol now just remember ncds they develop the guidance and guidelines for the ncds and the max develop the guidelines and guidance for the LCDs now what if something comes back not covered it's just not going to be covered well the provider has a duty to tell the patient that this service is not going to be covered and if when that service is 100 or more they have to give the patient an advanced beneficiary notice and a b n and it looks like this it looks like this and if that provider fails to provide that ABN patient may file a claim with the civil rights office and that provider will have to eat that payment they would have to just waive it so if a patient goes in there and they have this extensive procedure and they were not given this ABN and it's not covered the doctor just gave away free services and if it's a facility they use a form called the h-i-n-n and it looks like this and there are various um types of h-i-n-ns you have one for pre-admission um that's h-i-n-n-1 h-i-n-n-2 when the hospital and doctor don't agree on the patient's admission h-i-n-n-11 medically unnecessary Diagnostic and therapeutic services and h-i-n-n-12 Hospital appeals so this is an h i n n 11. all right so medically medical necessary is it and so you're like oh miss Jay you're just really honing in on this medical necessity what does that have to do with oig because I kind of left oig it's a lot okay but before I do that I just want you to know this is how medical necessity is established number one the diagnosis must justify the treatment rendered if the provider doesn't know for sure then they can access the McD then consult the NCD if there's no NCD look for the LCD if there's no LCD reach out to your Mac in your jurisdiction now even though the government says hey you have to have medical necessity to substantiate procedures providers and Facilities also have to operate in a compliant way because it's very easy these these providers are often independent so it's very easy for them to not document properly so there is oversight and that office of Inspector General they're going to investigate Fraud and Abuse and the office of Inspector General mandates that providers and Facilities have effective oig compliance plans right so this is one way that providers and Facilities self-regulate so that they don't commit Fraud and Abuse and one of the things they do they have to do as mandated by oig they have to conduct internal monitoring in an auditing they have to implement compliance and practice standards they have to designate a compliance officer or contract they have to conduct appropriate training and education respond appropriately to detect offenses and develop corrective action they have to develop open lines of communication with employees and enforce disciplinary standards through well-publicized guidelines and the office of Inspector General they produce a work plan and it's published twice a year and this work plan tells providers and Facilities what the focus what their focus is going to be how are they going to regulate Fraud and Abuse what areas are they focusing and you can go right to the oig website and see what's up next and guess what I did I went to the office of Inspector General work site office of Inspector General work plan site to see hey what's coming up next and what caught my eye is the use of remote patient monitoring services in Medicare I'm like what is that so I clicked on it and basically they are going to determine the extent to which provider billing for remote patient monitoring Services May indicate fraud waste or abuse so doctors facilities if you have patient monitoring services make sure that they are operating above board because the oig that is their focus so at least they warn you okay all right so let's talk a little bit more about oig Fraud and Abuse and then we're going to switch gears and I'm going to hand it over to miss Tamika all right so oig enforces and investigates fraud of and abuse crimes in health care and HIPAA says fraud is defined as knowingly and willfully executing or attempting to execute a scheme to defraud any health care benefit program or to obtain by means of false or fraudulent pretenses representations or Promises of any of the money or property owned by any health care benefit program so I would just say HIPAA fraud is knowingly and willful Behavior right knowingly and willful abuse that's defined as incidents or practices not usually considered fraudulent that are inconsistent and acceptable sound medical business or fiscal practices in other words it's waste full and if Physicians and accomplices are found to have committed fraud and or abuse they can receive penalties including jail time and when I'm saying accomplices do you not think that a coder can be considered an accomplice absolutely and if you have time go to the oig Fraud and Abuse website you can see all of the providers that have been um charged with fraud and it's not just providers there's a lot of coders and billers indeed all right so we've got a Fraud and Abuse exercise are you ready remember fraud is to knowingly and willfully deliberate it's a deliberate attempt to deceive right and it's also breaking any kind of law or contract just thought I would let you know that all right is it fraud or abuse Dr Thomas Smith builds Medicare beneficiaries for insurance only and never collects a co-payment or deductible is it fraud or abuse what say you type your answer in the chat all right I see a few answers and I know some people may be stumped but go with your gut which is it yeah my gut would say it's abuse however think about it every doctor has a contract with Medicare and in that contract it says hey you have to collect a co-payment and you have to collect a deductible so if they are breaking the contract willingly and knowingly than it is fraud okay good job good job and if you didn't know now you know and that is priceless all right got another question a patient Carl Skinner calls the office repeatedly about his prescriptions when seen in the office the next time Dr Jones builds a higher level of evaluation and Management Service to allow for the additional time is this fraud or abuse alright so I'm just going to tell you it could be both right and here is why because if you alter your fees for services then that's fraudulent like a lot of doctors publish their fees if they alter them then that's fraudulent however the doctor can bill whatever they want to build right but it's going to be denied anyway so it's fraud it's abuse but for this we'll say it's fraud all right a lot of you probably said fraud too but I think we need more um clarification right so you can't alter your fees but you can charge whatever you want and that's a b that's abuse because it's wasteful it's going to be denied anyway but if you're billing that client the residual that's fraud all right so we got another one a Medicare patient Joan O'Connor is seen by Dr practon and the insurance claim shows higher rates for Medicare beneficiaries than non-medicare payments is this fraud or abuse so in other words the doctor charges Medicare patients more than non-medicare is it fraud or abuse that's right it is abuse the doctor can bill whatever they want it is abuse um and the the insurance company is going to pay their contracted rate and no more okay so it is an abuse it's wrong all right Dr skeleton sets a simple fracture and puts a cast on Mr Davis but he builds for a complex fracture is it fraud or abuse absolutely fraud fraud fraud yes you can't build for something you didn't do you you need to build for a simple fraction not a complex fracture all right we have two more then I'm going to hand it over to miss Tamika all right a patient Hazel Plunkett had Botox fillers injected the fillers are not covered under her insurance policy as they are determined not medically necessary to the extent rendered however an insurance claim was submitted is this fraud or abuse you you are rock rock rock come on give me some more answers wake up wake up wake up all right indeed this is abuse you knew it wasn't gonna get paid why are you wasting someone's time remember abuse is waste and finally is this fraud or abuse a patient Maria Gomez asked a friendly staff member to change the dates on the insurance claim form the medical assistant complies with the request is this fraud or abuse man you all are blazing through the chat so quick you all said this is fraud on so many levels absolutely it is fraud no explanation needed all right so I am very very happy to say that we have finished our discussion on Medicare HIPAA soap oig and Fraud and Abuse and if you have questions go ahead type them in the chat and on that note I'm gonna hand it over to miss Tamika take it away thank you Mrs J and I think that we all are sitting here going wow wow wow and I think definitely we've all learned something I know I have I mean I thought I knew some things but I have learned even more and even more astonishing is realizing that hey coders we need to understand what we should and should not do so that we are clear when others are trying to do things they shouldn't do that we know not to get involved so I think that's critical and we are very clear that we have a pivotal role to play so thank you Mrs J for even more clarity and for a phenomenal phenomenal lecture and I think that we are clear on Fraud and Abuse so we always have scenarios but we just have a quick a few little quick uh review questions just to give you a general overview of the business of medicine some general takeaways and this will not take long so we're going to do just a quick multiple choice and type your answers in the chat that the notification from The Physician to the Medicare patient that a service is not covered what is that called coders so I want to hear from you briefly in the chat and the few that I have for you are going to take all of five minutes to go through so let me hear from you what is that notification called yeah I see a few people is trickling in and these are things you'll definitely want to be clear about yeah I see some people putting a question mark by it yeah so what do you think coders this is a notification from that provider that that service is not going to be covered that is indeed the a b in right so what does ABN stand for is it Advanced beneficiary notice admitting beneficiary notice advisory beneficial notice or Advanced benefits notification so what does the ABN stand for so if you weren't sure what the prior question meant what does the ABN stand for now that you know that answer that's something that we need to be aware of that indeed as a patient you would want to know in advance what will be covered you don't want to get that final notice that past dude you're like what what what what wait a minute that's not what they said all right so we must have the advanced beneficiary you notice that had to be given to the patient prior to the procedure we must know all right so when our providers responsible for obtaining the ABN for service not considered medically necessary and Mrs J spoke about that that it has to be considered medically necessary in how that's established is this after providing a service or item to the beneficiary or is it prior to providing that service or item to a beneficiary is it during the procedure or service or is it after a denial has been received from Medicare so what say you coders what are these providers responsible for obtaining that ABN for service not considered medically necessary because we already know that you don't want to have to eat that bill right so so surely folks are going to follow unless their services are going to be for free yeah we've got it we've got a no prior to the service or item that is given or performed for that beneficiary we have to have the provider to obtain that okay before that service is rendered yes so what about HIPAA what does HIPAA stand for is it health insurance provider assistance action health insurance portability and accountant advice health insurance portability and accountability act or is it health information Public Access Act what is HIPAA how are you HIPAA compliant what is it okay so some of you are typing typing in the chat I'm going to start sharing some of my VA energy drink that's what I'm gonna do that's what I'm gonna do y'all all right it is C health insurance portability and accountability act and Mrs J gave you definitely the back story on what HIPAA stands for and what originally what it meant and when it came to be and why so true or false HIPAA mandates the usage of medical codes what do you think does HIPAA mandate the use usage of medical codes and you remember Mrs J gave us the back story on HIPAA and some of its functions yeah yeah some of you remember some of you remember so it's a little bit of a split and indeed HIPAA does mandate the usage of medical codes all right so I can believe this is our final one what is the Phi is it the physician Health Care interchange or protected health information or is it private health insurance or provider identified incident too so what is t-h-i and this is definitely critical for us and anybody else right we want to be sure that with p h i b it is our protected health information it's anything that links us to our health status that is your Phi yeah I see someone saying yay all right this is our last one minimum necessary rule applies to who and this is critical because really this is really as an as to need no basis like what is the minimum necessary rule does it apply to disclosures to or requests by a health care provider for treatment purposes or is it B disclosures to the individual who's subject to the information for uses or disclosures that are required by other law or covered entities taking reasonable steps so what is that coders what does that what does that cover all right so I see I see some answers coming in the chat and yeah that one is indeed it's covered entities taking reasonable steps really you don't want anybody handling certain parts of your medical record that don't need to it's really on an ass to need no basis a need to know basis so congratulations to you coders yes you have made it through your first eight weeks and you have moved through part one we are so excited and delighted that you guys have taken these first steps again you have laid the groundwork and it's time to move on some to some more Coatings of in-depth coding and we're looking forward to you joining us you all are amazing team I think each and every one of you to miss keitha for being phenomenal being a co-lead to these part one coders and for helping the team and interns we cannot do it without you you all help to extend our reach and to make the experience of our part one coders phenomenal and we thank you your efforts are greatly appreciated as always we really appreciate you coders use this time to get that work done and we will see you in part two all right have a great one and we will see you all again real real soon have a great day coders foreign [Music] [Music] see I am c i a m c i am [Music]