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    Question credentialing question please

    Talk to your managed care department and let them know what is going on. They need to contact their enrollment contact to ensure all related tax IDs associated with the enrolled provider are part of the enrollment. You must use the NPI and tax ID specific to the location where the service was...
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    No pre-auth, provider responsibility?

    You could bill the patient; however, if you are an enrolled healthcare provider with the payor, you must follow the contractual terms of the agreement in addition to the guidelines set forth in the provider manual. Following adjudication, if denied for no authorization, you might be obligated to...
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    Question CPCO Exam Study tools

    Study anything and everything on this page. Know it inside and out. Study it so much that you can teach it to others or be able to speak to it. Become the expert. It is not an easy exam. But, if you know the material, you will do well and will join others, including myself, that have become...
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    @slwalsh , The patient might be mutual; however, the patient is not being seen by the other healthcare provider in conjunction with services provided by your office. You must have the patient's written authorization for release before providing a copy of PHI to the other provider. Scott B, CPCO
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    Remote work compliance form

    Katelyn, I am not aware of a distinctly different form for maintaining compliance remotely. In my company, all employees must successfully complete various training that address compliance, privacy, fraud, and waste. It is my assumption that an employee is expected to adhere to all compliance...
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    False Claims Act?

    My recommendation is to only submit a claim for a lab test that was both ordered and performed. Submitting a claim for a test not performed could be a potential false claim. On the claim form, you should enter (into box 32) the name, address, and zip code of the facility (laboratory). The CMS...
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    Non certified coders

    I agree with @thomas7331. Furthermore, there is an expectation by the government of those providers participating in federal programs to know the rules/regulations of the programs. Even if ignorant, if the provider seeks payment, the government will seek to hold the provider responsible and...
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    CPCO Exam Question

    Anndrellebutler, That is true. You cannot bring any material from the course. Please read page two of the this document. For the CPCO exam, you may bring: "Any published references are allowed, except Study Guides and published references by HCCA"
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    CPCO Exam Question

    1.) Print the pages from the published Federal Register that contain the OIG Compliance Program Guidances. 2.) Place these printouts in a binder 3.) Read each guideline 4.) Analyze each guideline - How are they different? What are their similarities? 5.) If called to teach these guidelines as a...
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    New to Compliance and need direction.

    If the provider requests that this direct employee accesses the record for a particular purpose, that should be okay. The person accessing the file must only access the part of the record that is required to accomplish the task. In other words, the person is not to snoop around to other areas of...
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    Hospital policy vs Medicare Guidelines

    Can you rephrase your question? I'm having trouble following.
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    Is it in compliance to...

    Always follow office written policy regarding resubmission of a corrected claim. If one if not in place, help to create one. Also, monitor the guidance provided by the payor. Some payors will require you complete one of their forms to explain the correction. Systematically, if you can correct...
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    compliance exam

    I took a large binder filled with printouts of Compliance Guidelines from the Federal Registry. If you do the same, use dividers to separate the different guidelines. Do NOT go into the exam expecting that you will have time to look for information. You will not have time to search for the...
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    CPCO Certification - course through AAPC

    Any published reference except study guides and any published references by HCCA. I would not recommend anything published by either AAPC or HCCA. Ideas: A Roadmap for New Physicians - Avoiding Medicare and Medicaid Fraud and Abuse - Published by US Dept of Health & Human Services Each of the...
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    EMTALA question

    Great question. Keep in mind that the purpose of EMTALA is to ensure public access to emergency services regardless of ability to pay. If the patient is admitted and continues to have an emergency medical condition, the hospital must continue to provide stabilizing treatment. In a document...
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    CPCO Certification - course through AAPC

    sisleidy22, For the CPCO exam, any published references are allowed, except Study Guides and any published references by HCCA. I took a HUGE binder with dividers. Most of my material was from the Federal Registry. I did not take notes with me, but I did underline and highlight key points I...
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    Records Retention-Insurance E.O.B's

    I am not aware of a statute for retaining insurance EOB or remits. If one does not exist, the practice or facility should develop a retention policy that clearly defines the duration of time required. Remember to protect the PHI at all times while maintained. If the practice or facility...
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    Hippa violations

    If the practice has a compliance officer or one that performs the task of a compliance officer, you should first report the concern to that person. If there is a hotline, you can call that as well. You can review the OIG Compliance Program for Individual and Small Group Physician Practices...
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    Can a Medical Coder change a Dx or procedure code that Dr selected

    How would you document such a change? If I am auditing an account and identify that the coder did not use the dx code selected by the healthcare provider, I would want to see some documentation explaining the rationale for selecting something different. Also, there should be a clear documented...
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    Shannon, For the CPCO exam, any published references are allowed, except Study Guides and any published references by HCCA. I took a HUGE binder with dividers. Most of my material was from the Federal Registry. I did not take notes with me, but I did underline and highlight key points I...
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    Any published references are allowed, except AAPC Study Guides and any published references by HCCA. I recommend reviewing the list of medical compliance resources provided on the AAPC website. Each contains a link to a wealth of information...
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    Is this fraud?

    It is considered fraud if the provider is doing it with intent to deceive the payer for the purpose of obtaining reimbursement. It is considered abuse if there is no intent to defraud the payer but the outcome from the billing mistake results in reimbursement. Regardless of if it is fraud or...
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    fraud in billing?

    nicely stated!
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    Hipaa Question regarding minors

    A patient who wants to pay cash can instruct the provider to not share treatment information with his or her health plan. A good article to read is this. Scott
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    If your practice has a compliance hotline, you can report your concerns in that manner. This will accomplish a couple of things. First, the concerns will be documented and a review can begin. Two, there is likely a non-retaliation rule for reporting you so are protected. If your practice does...
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    81507 vs 81420

    Jojof, Both are used for NIPT; however, 81407 is a MAAA and is unique to a single clinical laboratory. 81507 is listed in Appendix O of the 2016 AMA CPT book. According to this appendix, this was created for Harmony Prenatal Test, Ariosa Diagnostics. Scott
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    Gene analysis

    Amanda, Neither gene is specified in the listed molecular pathology codes; therefore, both should be reported with 81479 (unlisted molecular pathology code.) Scott
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    Genetic screening for cardiovascular disease

    I have a provider that wants to order a screen for sudden cardiac death and other cardiovascular anomalies. There is no indication. This could be a patient going through a pre-surgical work-up. ICD-10 could be Z13.79 (Enc for other screening for genetic and chromosomal anomalies) Is there a...
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    CPCO-Approved references

    I am also considering the CPCO. Was the large binder with references useful during the exam?
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    Billing for indeterminate results

    If a lab is unable to finalize a report due to poor sample quality, can the lab report out as 'mutation status indeterminate due to poor sample quality' in order to seek reimbursement for costs incurred? My opinion is that the lab cannot bill unless the test can be completed in its entirety...
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    Medicare and CPT 81225

    Review the LCD (L33638) and look in section two of the coverage guidelines. The section specifically speaks to coverage conditions of CYP2C19.
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    83789 - Number of units, 1 or 10?

    We are considering the use of 83789 to obtain values for 10 different bile acids (each being a different analyte that is individually reported.) We would use mass spectrometry and tandem mass spectrometry to perform this test. Those ordering the test would send us 1 tube of plasma (approx. 2cc)...
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    dna testing

    For most of these, you will use 81479 (unlisted MoPath code) You can find SCLO1B1 under 81400 (Tier 2 code). Look at the description. If it matches, use 81400. If it does not, use 81479. You can find APOE under 81401 (Tier 2 code). Look at the description. If it matches, use 81401. If it does...
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    Payment on claim

    Here is the link to the information provided by BCBS-TX. I expect other insurance payers to do the same or something similar. The form is located at I noticed...
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    Payment on claim

    81401 is a Tier 2 MoPath code and 81479 is an unlisted MoPath code. 81401 - The specific gene must be listed in the Tier 2 code. In addition the associated procedure must be listed as well. For example, you can use 81401 if you are testing for common variants of APOB; however, you cannot use...
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    medicare LCD L30538

    I see on Novitas website where it says (through a search) that the effective date is 05/08/2014. If you look at the revision history explanation on the policy, L30538 retired on 12/05/2013 - "Retired effective for dates of service on or after 12/05/2013. The key information has been absorbed...
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    Laboratory Billing

    For LOINC, you can visit They also have a twitter account that I follow. I found it to highlight current information. I've also found a few educational resources about LOINC on YouTube. sab001
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    Dx code for abnormal ultrasound (pregnancy)

    The specifics are not always provided by the ordering provider. All that the provider checks off is 'abnormal ultrasound.' No other information is provided. The lab test is designed to test for fetal aneuploidy of chromosomes 21, 18, and 13. sab001
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    Dx code for abnormal ultrasound (pregnancy)

    I work in a diagnostic laboratory that performs molecular testing. One of our test is intended for patients considered to have high-risk pregnancy. When reviewing the coverage policies for this test, multiple insurance companies list 'abnormal ultrasound' as one of the reasons for covering the...