Regulatory Compliance
The frame
Compliance means submitting claims that are supported by the record and by payer rules - no more, no less. Know the seven elements of an effective compliance program (written policies and procedures, a designated compliance officer and committee, effective training and education, effective lines of communication, internal monitoring and auditing, well-publicized disciplinary standards, and prompt response and corrective action).
Key laws and programs
False Claims Act liability attaches to knowingly submitting, or causing to be submitted, a claim that is false or unsupported - including reckless disregard. The Anti-Kickback Statute and Stark Law govern remuneration and physician self-referral. HIPAA sets privacy and security duties, including minimum necessary use and breach notification. Medicare contractors include MACs, RACs, and UPICs; NCCI edits and medical necessity rules apply to every claim.
Coverage and billing rules
Know the difference between an NCD (national) and LCD (local) coverage determination, the role of medical necessity, and the Advance Beneficiary Notice, which must be delivered before the service so the patient can choose to accept financial responsibility. Understand the two-midnight benchmark and how observation versus inpatient status affects both coding and billing.
Common traps
Dropping a code to force payment; unbundling to increase revenue; billing a service with no order or no authentication; assuming "we've always done it this way" is a defense; and altering a record after an audit rather than amending it properly. Disclose and correct - never overwrite.
Rule of thumb
If the documentation cannot support the code as written, the answer is a query or an amended record, not a creative code assignment.