Coding, Billing, and Reimbursement Compliance
Core Risk Areas
The classic billing risks are upcoding, unbundling, duplicate claims, services not rendered, services not medically necessary, diagnosis miscoding to justify payment, modifier misuse, place-of-service errors, and documentation that fails to support the code billed. Medical necessity is the linchpin: documentation must support both the level of service and the clinical rationale.
Rules a Candidate Must Know
Evaluation and management level is determined by medical decision making or total time, using current definitions and rules on what counts toward time. Incident-to billing requires an established patient, an established plan of care, direct physician supervision, and the service being an integral part of the physician's course of treatment. Teaching physician rules require the physician's presence and documented participation. NCCI procedure-to-procedure edits carry modifier indicators: 0 means never allowed, 1 means a modifier may be appropriate, 9 means the edit is not applicable. Medically unlikely edits set unit limits. The two-midnight rule governs inpatient admission presumption.
Traps
"Documented" does not equal "medically necessary." Copy-forward, cloned, and pre-populated templates create false documentation. Incident-to may not be used for new patients or new problems. A signed note can still be an unsupported note.
Worked Example
An audit finds 30% of level-4 established patient visits supported only at level 3. The corrective action is repayment of the difference, root-cause analysis (template design, coder feedback, EHR defaults), pre-bill review for a defined period, and targeted education - not re-education alone.
Rule of Thumb
If it is not documented in the record, it was not done; if it is documented but not medically necessary, it should not be billed.