ADDRESSING MEDICAL CODING AND BILLING

PART II: A STRATEGY FOR ACHIEVING COMPLIANCE A RISK MANAGEMENT APPROACH FOR REDUCING CODING AND BILLING ERRORS
Diane L. Adams, MD, MPH, Helen Norman, MA, and Valentine J. Burroughs, MD Washington, D.C.

A Training Module for Health Care Providers

Medical practice today, more than ever before, places greater demands on physicians to see more patients, provide more complex medical services and adhere to stricter regulatory rules, leaving little time for coding and billing. Yet, the need to adequately document medical records, appropriately apply billing codes and accurately charge insurers for medical services is essential to the medical practice's financial condition. Many physicians rely on office staff and billing companies to process their medical bills without ever reviewing the bills before they are submitted for payment. Some physicians may not be receiving the payment they deserve when they do not sufficiently oversee the medical practice's coding and billing pattems. This article emphasizes the importance of monitorng and auditing medical record documentation and coding application as a strategy for achieving compliance and reducing billing errors. When medical bills are submitted with missing and incorrect information, they may result in unpaid claims and loss of revenue to physicians. Addressing Medical Audits, Part I - A Strategy for Achieving Compliance - CMS, JCAHO, NCQA, published January 2002 in the Joumal of the National Medical Association, stressed the importance of preparing the medical practice for audits. The article highlighted steps the medical practice can take to prepare for audits and presented examples of guidelines used by regulatory agencies to conduct both medical and financial audits. The Medicare Integrity Program was cited as an example of guidelines used by regulators to identify coding errors during an audit and deny payment to providers when improper billing occurs. For each denied claim, payments owed to the medical practice are are also denied. Health care is, no doubt, a costly endeavor for health care providers, consumers and insurers. The potential risk to physicians for improper billing may include loss of revenue, fraud investigations, financial sanction, disciplinary action and exclusion from participation in government programs. Part 11 of this article recommends an approach for assessing potential risk, preventing improper billing, and improving financial management of the medical practice.

While health care spending in the United States is rising, physician reimbursements may be declining. Health care is a trillion-dollar-a-year industry and health care spending is steadily increasing at a rate of 2% to 3% annually. Yet, some physician's revenues may not be increasing at a comparable rate. Health
2002. From the National Medical Association, Washington, DC. For reprints, contact Dr. Diane L. Adams, 1012 Tenth St., NW, Washington, DC 20001-4492; or send e-mail to dadams@NMANET.ORG.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

care and business analysts report that physicians may not be receiving their fair share ofhealth care dollars. "That's the dilemma facing many doctors today who have overhead costs that are going up faster than their revenues," according to the American Medical Association ("Losing Proposition: When Doctors Take In Less Than What Goes Out," American Medical News, Jan. 7, 2002). There are several factors contributing to the rising costs of health care and declining reimbursements to physicians. However, this article examVOL. 94, NO. 6, JUNE 2002

430

HEALTH POLICY

ines medical coding and billing in relation to loss of revenue to physician practices. We outline a risk management approach to addressing both compliance and reimbursement concerns. With medical coding and billing from a risk management perspective as the focus, we examine the cost ofhealth care, present important information on medical coding and billing, direct the reader to additional resources on the subject, and offer a risk management strategy for analyzing billing practices. A major focus of the US Department of Health and Human Services (DHHS) and its Office of Inspector General (OIG) since 1996, the government's heightened investigation of hospitals, nursing homes, physical therapists, outpatient rehabilitation facilities, and physician practices has reportedly resulted in increased denials of improper claims and reduced payments to providers. According to the OIG, the Centers for Medicare

and Medicaid Services (CMS) improperly paid $12.1 billion, approximately 6.3% of the $191.8 billion, for fee-for-service Medicare in FY 2001. Improper payments in FY 2000 were estimated at about $11.9 billion, compared with $13.5 billion in 1999 and $23.2 billion in 1996. DHHS' goal was to reduce the Medicare payment error rate to 7% of total budget by FY 2000 and further reduce improper payments by 5% in FY 2002.2

HOW MUCH IS SPENT

The National Coalition on Health Care (NCHC) reported health care spending for 2001 to exceed $1.54 trillion. "That is four times what was spent on health care in 1980 and is projected to exceed $2.3 trillion by 2009." In the NCHC report, Facts on the Cost ofHealth Care, general inflation is projected to increase at a rate of 3% annually between 2000 and 2004 while health care inflation is projected to increase by 8% annually during the same period.3 The NCHC report, Health Care Facts: What You Need To Know, reported that American consumers are spending about one of every eight dollars on health care. In 1998, American spending on health care accounted for $1.1 trillion or "$4,000 for every man, woman and child in the country." Health care costs have been rising at about twice the rate of income since 1980. It is projected to double again to $2.1 trillion by 2007.4 Government spending on health care also is on the rise, according to the US Commerce Department's Census Bureau. The Census 2000 report provides an accounting of federal government spending at more than $1.6 trillion for domestic products and services in fiscal year 2000, a 6% increase over 1999. Social Security, Medicare, and Medicaid reportedly accounted for $781 billion in 2000 or 48% of the US government's domestic spending. Medicare spending for 1999 was reported at $216 billion, a 3.4% increase over the previous year. Medicaid payments to states under federal grant awards totaled $121 bilVOL. 94, NO. 6, JUNE 2002

Top 10 Billing Concerns for Physicians,

1. Medicare billing (Part A and Part B). 2. Mental health billing. 3. Self-referring to entities where the physician has a financial interest. 4. Billing for services provided at certain state-owned sites (i.e., prisons). 5. Not differentiating between outpatient clinic and physician office visits. 6. Improper use of "25" modifier. Use with E&M codes for day of surgery. 7. Not returning overpayments to Medicare

immediately.
8. Billing multiple anesthesiology services at individual, not concurrent, rates. 9. Billing critical care by the hour, not by documented patient care. 10. Upcoding by billing service companies on behalf of the physician.

Reference
1. hcpro's complianceinfo.com, "Ten points of OIG con cern." Physician Practice Compliance Report.

431

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

HEALTH POLICY

lion. Medicaid payments were up 9.1% in 2000.5 The fiscal year 2001 budget for DHHS was $429 billion. DHHS' budget was allocated to biomedical research, reorganization of the Medicare and Medicaid agency, a multifaceted Disease Prevention Initiative and new action aimed at pro-

according to Medical Group Management Association's 2000 Cost Survey. Operating costs for multispecialty groups went up an average of 35% over the past 10 years, but revenue increased only 21% over that same period." (American Medical News, Jan. 7, 2002) The economic impact of patient non-compli-

Where the $1.1 Trillion Goes

tNA$n *om
and Elaine Cawe

Mtedkcal Rese.ard 4%

Publkc Ileahh and

Costs
6%

Evie. aE|r.% Ov. I

HF%

Denial. *nAtL

Source: Health Care FinancingAdministration

tecting the American people against specific diseases (HHS Fact Sheet, US Department of Health and Human Services, Dec. 31, 2001).

Why So Costly?
Several factors are contributing to the rising cost of health. Consumers demand more complex services from health care providers. Medical technology, equipment and laboratory tests are more costly. Pharmacy costs have increased for both consumers and providers. The number of uninsured consumers continues to increase; thereby, passing the cost onto practitioners, insurers and purchasers. The American Medical Association reports that the cost of running a practice has increased due to steep hikes in health and malpractice insurance premiums (American Medical News, Jan. 7, 2002). American Medical News reports that medical costs are outpacing revenues for many physicians. "Increases in medical practice costs outstripped revenue increases over the past 10 years,
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

ance with treatment protocols and prescription drug regimens affect the rising cost of health care. Non-compliance with drug regimens may mean a patient fails to fill or refill a prescription; delays getting a refill before the prescription runs out; or takes the drug in a manner other than how it was prescribed. The act of non-compliance by patients may result in increased emergency room visits and hospitalizations. Pharmacy costs may increase as a result of filling the same prescription multiple times. Millions of workdays are lost annually due to lack of productivity in the workplace and increased employee absenteeism as a result of noncompliance with treatment regimens and prescrip-

References
2. US Department of Health and Human Services, HHS News, March 6, 2001. 3. Health Care 2000, "Facts On The Cost of Health Care." 4. National Health Care Coalition, "Health Care Facts: What You Need to Know." 5.Census 2002, "Federal Domestic Spending Up 6 Percent in 2000; Five States Received One-Third of All Funds, Census Bureau Reports."
VOL. 94, NO. 6, JUNE 2002

432

HEALTH POLICY

tion drug regimens. The costs of patient non-compliance are passed onto health care providers, consumers and purchasers. Some analysts say the rising cost of medical care simply boils down to supply and demand. According to a Duke University report, today's "consumers want the best doctors, the newest treatments, and cutting-edge technology. These demands are understandable, but they do cost more. Americans are using more and more expensive prescription drugs than ever, which drives up health care costs."6 It is projected that over the next few years, more than 76 million baby boomers will reach or approach their senior years. Many will also become eligible for Medicare benefits. Federal spending on health care is projected to increase proportionately with an increased number of seniors taking advantage of their Medicare benefits. Health care spending is expected to be influenced by baby boomers' desire to remain youthful, productive members of society who will also drive the development of new and costly medical technologies, treatments, drugs and services. NCHC identified several other factors contributing to the high cost of health care, including7: * Inappropriate and unnecessary care and medical errors; * An oversupply of hospital beds and specialty doctors; * Accelerating costs for physician and other health professionals' services relative to other countries; * Excessive medical testing to protect against malpractice suits; * High costs in administering health care; and * Excessive and inappropriate treatment at the end of life.

ed, the cost of providing health care to these consumers is often passed onto health care providers. Additionally, children's health initiatives, preventive health services, public health research and health care policy development contribute to the rising cost of health care. The cost of providing quality health care to all Americans is an expensive endeavor for physicians, consumers, insurers, purchasers and government agencies. With the cost of health care increasing at a rate of 2% to 3% annually, it is imperative for physicians to receive timely and accurate reimbursement for services provided. Reducing errors in medical coding and billing may be one step toward reducing loss of revenue on improperly coded claims. Whether the physician delegates medical coding and billing to office staff or billing services, it is essential for physicians to periodically review coding and billing documentation as a strategy for assessing financial risk and potential loss of revenue.

IMPROPER CODING/BILLING RISKS

DHHS has revised its procedures for reviewing, paying and monitoring Medicare reimbursements. The OIG has advised physicians to fully document their services and implement compliance plans in order to reduce coding errors, and bill only for medically necessary services. Other Federal and State enforcement agencies, such as Department of Justice, Attorneys General and Medicaid Fraud Units, have implemented initiatives to detect and investigate health care providers who submit false claims. CMS redefined the term "erroneous claims" to assure physicians that the OIG has not targeted for investigation providers who make innocent billing mistakes. However, a pattern of submitting "erroneous claims" may initiate an investigation by both Federal and State enforcement agencies. Erroneous claims can be classified as applica-

Who Pays for Uninsured?

The cost of providing quality health care to the nation's uninsured consumers is another contributing factor to the rising cost of health care. The topic is continually debated at state and national levels. However, while the issue of providing health care to uninsured Americans is being debat433 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

References
6. Duke University Medical Center Office of Publications. 7. The National Coalition on Health Care, Health Care Facts: What You Need To Know.
VOL. 94, NO. 6, JUNE 2002

HEALTH POLICY

tions for reimbursements where innocent and common coding and billing errors have been made. Fraudulent claims, on the other hand, are classified as applications for reimbursements with reckless and intentional conduct to collect payments for services not provided.

High Risk Areas

The OIG has identified the following risk areas, which could be problematic for physicians (Federal Register, Volume 65, Number 113, "Compliance Program Guidance for Individual and Small Group Physician Practices"): 1. Billing for items or services not provided. 2. Submitting claims for equipment, medical supplies, and services that are not reasonable and necessary. 3. Double billing for the same service or item. 4. Billing for non-covered services. 5. Misuse of provider identification numbers. 6. Unbundling a multiple component service and billing each component as a single service. 7. Failure to properly use coding modifiers. 8. Upcoding the level of service provided. Because of its widespread practice, upcoding is a major focus of the OIG and is incorporated into the regulations promulgated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). To illustrate risks associated with improper coding, we will look at the practice of upcoding. Upcoding is defined as "billing for a more expensive service than the one actually performed." Medical record documentation is the evidence of coding and justification for billing. Failure of the physician practice to appropriately document the medical record could result in improper coding and erroneous billing.

The Physician's Risk of Upcoding 99214 to 99215

One of the great difficulties facing busy practicing physicians is the decision on the level of coding and billing. The choice often lies between selecting the highest possible billable code or
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

selecting the appropriate code for the level of service provided. In the case of established patients, the lower level Current Procedural Terminology (CPT) codes 99212 and 99213 are less often used by physicians than the higher codes 99214 and 99215 for most routine office visits. When practitioners develop a pattern of selecting a higher level code for a lower level service, that's upcoding. Many factors enter into the coding and billing decision. Two thoughts predominate the practitioner's thinking. The first is the economic incentive. There is a 25-30% increment in reimbursement for each higher level of coding. The second is the practitioner's perception of greater complexity when caring for today's more demanding and better-informed patients. It is difficult to properly code a "laundry list" of complaints and address issues of alternative (integrative) and conventional medicine simultaneously. This is further clouded by the complexity and confusion surrounding the Evaluation and Management (E&M) guidelines currently used by Medicare and other payers. For instance, Medicare will accept documentation for 99214 or 99215 using either the 1995 or 1997 guidelines. Whichever is easier for the practitioner to implement is acceptable. If one looks at the physical examination component for the 1995 E&M guidelines, it seems easier to implement in concept since less detail is required. For 99214, a complete examination of a single organ system is required without detailed content. For 99215 eight or more organ systems must be examined as part of a generalized multisystem examination. Under the 1997 E&M guidelines for physical examinations, a 99214 level visit should include 12 to 18 elements from at least two systems or areas (or two or more elements from six or more systems). A level 99215 visit should show an examination of 19 elements or more from at least nine systems. Because E&M guidelines are periodically updated, medical offices also must update their coding practices. It is important for practitioners to remain up-to-date with current guidelines and revise medical record documentation and coding procedures accordingly.
VOL. 94, NO. 6, JUNE 2002
434

HEALTH POLICY

Although it is difficult for busy practitioners to master and distinguish between two sets of guidelines, it is of utmost importance for practitioners to carefully select appropriate codes. Accurate documentation and appropriate coding must be evident in the medical record in order to support the amount billed. If it is not in the medical record, it did not happen. Practitioners also must be wary of sudden changes in their coding patterns. Profiles are created and monitored by payers to establish grounds for utilization reviews and quality control standards, but also to give leads on fraud and abuse. Dramatic increases in billing for higher level visits will often raise a red flag for payers, prompting an audit. During an audit, patterns of upcoding will require a high level of documentation to justify the coding decision. The temptation to upcode in the face of greater demands on the practitioner's time and economic challenges of clinical practice today must be overcome by the realization of potential penalties inherent in the practice of upcoding.

insurance claims. Claims processors, adjudicators, examiners, and auditors review medical claims and make reimbursement determinations. Federal and state laws establish statutory time frames for medical claims submission, payment and denial. Statutory requirements have also been established to allow providers to appeal denied claims. It is advisable for physicians and other health care providers to become familiar with claims appeal mechanisms in states where they practice medicine. Contact CMS for information on appealing denied Medicare claims. Most federal and state laws require insurers to reimburse providers as soon as practical, but no later than 30 to 60 business days after receipt of a claim, unless the claim or portion of the claim is contested. If the claim is contested, then the provider shall be notified in writing by the payer that the claim is denied (See Figure 1-An Overview of a Typical Claims Review). The denial notice shall identify the portion of the claim that is contested and specify the reason for denial.

WHAT YOU SHOULD KNOW Coding and Billing

The risks associated with improper coding can be costly for physicians. Medical bills may be denied and payments withheld by government and private payers when medical bills with coding errors are submitted for payment. Practitioners may be excluded from participation in any government-funded program under the False Claims Act. Federal and State regulatory agencies may impose financial sanctions and disciplinary actions on the medical practice. Therefore, it is prudent for providers to pay attention to changes in coding criteria, documentation standards and reimbursement requirements in order to reduce risks associated with improper coding and billing. Insurance companies, managed care organizations, Medicare, and Medicaid programs use similar criteria to review medical claims. CMS has imposed the most rigorous standards on providers for billing Medicare. State laws establish regulations for paying Medicaid, managed care and other
435

What is a Contested or Denied Claim?

A claim may be contested or denied by the payer if the entire claim or any portion ofthe claim cannot be paid due to: *use of insufficient or improper diagnosis and procedure codes; *ineligibility of patient for whom services are being billed; *billing for non-covered services under the health care benefit plan; *billing for unauthorized services; or *improper use of negotiated contract rates. Upon receiving notification of a denied claim, providers may request a review ofthe decision and attempt to get the denial overturned. An overturned denial could result in partial or full payment to the provider. If the provider does not receive payment or a denial notice within statutory time frames, the provider may be eligible to receive interest and penalty payments from the payer. Under certain federal and state "prompt payment" guidelines, payers who do not pay reimVOL. 94, NO. 6, JUNE 2002

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

HEALTH POLICY

bursements or send denial notices within specified time frames are required to pay interest and penalties to providers. It is in the practitioner's best interest to become familiar with "prompt payment" guidelines in states where they practice medicine. CMS can be contacted for information on "prompt payment" guidelines for Medicare claims. Auditors use medical record documentation during financial and medical reviews to determine appropriateness of coding and accuracy of billing. Providers may be required to repay Medicare, Medicaid and/or other payers for improperly coding claims and submitting erroneous medical bills. Insurers may terminate provider contracts and report medical practices to federal and state regulators. Medical bills, especially for Medicare and Medicaid services, which cannot be supported through adequate medical record documentation and selection of appropriate codes may be considered false claims and can be investigated under the False Claims Act.

Figure 1.

An Overview of a Typical Claims Review

Claims Flow Chart

Physician submits claims for reimbursement to payer.

Claims Review

Claims reviewers and adjudicators pay or deny claims within 30-60 days after receipt of 'clean claim.'

Medical Record Documentaflon and Compliance

The OIG's compliance program guidance advises practitioners to document medical records accurately and appropriately according to the level of service provided. Guiding principles have been established for documentation. Medical record documentation is viewed by the OIG as the basis for coding and billing determinations. The steps to achieving accurate and appropriate medical record documentation are outlined below: 1. Practice timely, accurate and complete documentation. 2. Use appropriate diagnosis codes for examination and personal history. 3. Link appropriate diagnosis with appropriate procedure code. 4. Use modifiers appropriately. 5. Identify other insurance coverage when billing Medicare.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Denied claims are returned to provider. Provider may appeal denied claim within 30 days of denial.

Claims Appeal

Appealed claims may be upheld or overturned by the payer.

If the denied claim is upheld, provider does not receive payment.

Claims Payment

If denied claim is overturned, claim is paid within 30-60 days of the overturned decision.
VOL. 94, NO. 6, JUNE 2002
436

HEALTH POLICY

The OIG's guidance recommends the following minimum compliance for medical record documentation: *The medical record should be complete and legible. *Past and present diagnoses should be accessible in the medical record. *Appropriate health risk factors should be identified. *If not documented, the rationale for ordering diagnostic and ancillary services should be easily inferred by an independent reviewer. *Patient's progress, his or her response to any changes in treatment and any revision in diagnoses should be documented. *Documentation of each patient encounter should include the reason for the encounter with any relevant history, physician examination findings, prior diagnostic test results, assessments, clinical impressions, diagnoses, plan of care, date of service and legible identity of the observer.

*All required information has been received and the claim is not contested nor denied. *The claim has been properly coded for only medically necessary services provided. *Payment liability can be established for a claim or any portion of any claim that is neither contested nor denied. *Paper and electronic claims shall be deemed complete and payable upon receipt of either: -A legible emergency department report; -Completed CMS 1500, UB 92, or format adopted by the National Uniform Billing Committee; -Electronic equivalent of the CMS 1500, UB 92, or its electronic equivalent as adopted by the National Uniform Billing Committee; -All reasonable and relevant information requested by the payer.

When 'Clean Claims' Rules Do Not Apply

The "clean claims" payment rules do not apply: a) to claims where there is fraud or misrepresentation; b) when eligibility determination is questionable; and c) in instances where the payer has not been granted reasonable access to information under the provider's control. These claims are automatically denied in most cases. The provider shall be notified in writing, within specified time frames, of the claims payment rules and that the claim is being denied.

Claims Payments
Before a medical bill can be paid, claims reviewers and examiners determine if all required documentation has been received. Claims adjudicators determine whether billed amounts and coding levels are consistent. Claims auditors perform retrospective and concurrent review of claims to determine accuracy and appropriateness of payments. If underpayment, overpayment or improper payment has occurred, an adjustment to the payment is calculated. If overpayment or improper payment has occurred, providers are notified to remit the amount overpaid to the payer. Most payers pay claims within specified timeframes upon receipt of a "clean claim," usually within 30 to 60 business days. It is important to note that where federal and state laws require "prompt payment" of claims, payers cannot ask providers to waive their right to interest or penalties owed them due to a delay in payment for any reason. Professional and institutional claims are considered "clean" if they meet the following criteria:
437 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Delay of Payment Rules

Some claims payment systems include an automatic delay of payment pending receipt of additional documentation; an exception applies in instances where payers have amended payment rules for professional claims. A payer may not delay payment on a claim from a physician or other provider to wait for a claim from a hospital or other institution without providing specific rationale in writing as to why the delay is necessary. The payer shall provide periodic updates to the provider regarding the status of the claim and the payer's actions to resolve the claim.
VOL. 94, NO. 6, JUNE 2002

HEALTH POLICY

Coding and Payment Rules

According to the online article, "Correct Coding Helps You Get Paid," by Physiatrist.com, physicians are advised to keep the most current edition of the Current Procedural Terminology (CPT) book on hand and review the introductory section of the book's instructions on coding Evaluation and Management (E&M) services. "Physicians can use any code, but most use the same 20 to 30 codes specific to their specialty." Since many medical practices use office staff to perform the task of coding medical bills, it is critical for medical office personnel to be well trained in coding and billing criteria. "Correct coding is crucial in getting paid fairly for your services." Seven key points from the article are summarized below: 1. To ensure that a precise description of the level of service performed is submitted, physicians should not fully delegate coding responsibilities to their staff because several different codes can be used to describe the same procedure. 2. Carelessness in linking diagnosis and procedural codes can lead to denied claims. The diagnosis or clinical suspicion must be present for the procedures to be considered medically necessary. 3. Make every effort to code to the highest level of specificity. Many office staff check the alphabetical index of the ICD-9 book (the International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-M], was developed by the National Center for Health Statistics for use in the United States. It is based on the World Health Organization's international ICD-9. A version based on ICD- 10 [ICD- I 0-M is in preparation]) for the patient's condition, but do not cross-reference to the list of diseases for the most specific code. This is considered a truncated or incomplete diagnosis and will be denied. The alphabetical index of the ICD-9 book contains diagnosis and procedural terminology and the tabular list of diseases arranges codes and their descriptors in numerical order. The tabular list should be used to select the highest level and most appropriate code possible. The alphabetical index should be used for reference purposes
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

only. Do not code from the alphabetical index. 4. Avoid using signs and symptoms to describe a medically necessary procedure or service provided when the diagnosis in not apparent. It must be supported by ICD-9 codes listed in the book not by descriptive terms, such as "suspected" or "rule out." 5. Document the patient's chief complaint, as this information provides evidence to the insurance company of the reason the patient sought medical services. 6. Determining whether to code an office visit as a consultation or a referral is challenging for some specialists. A consultation is a rendering of advice based on your professional opinion, followed by a report of your findings to the primary care physician. The patient then usually returns to the primary care physician. If medical care is provided to the patient, the visit is a referral and should be billed as a new patient. 7. Unbundling refers to the practice of using a multiple component service and billing each component as a single service. Unbundling, whether intentional or not, is considered by payers to be a form of fraudulent or reckless billing. 8. Periodically review diagnosis, service, and procedure codes with the office staff. Health Care Financing Administration (HCFA) coding guidelines, components, and required documentation should be reviewed frequently. Review billing codes that require modifiers in order to receive the maximum reimbursement. Physicians should be familiar with these modifiers and use them consistently. Modifiers provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers may be used to indicate: a) a service or procedure has both a professional and technical component; b) a service or procedure was performed by more than one physician and/or in more than one location; c) a service or procedure has been increased or reduced; d) only part of a service was performed; e) an adjunctive service was performed; f) a bilateral procedure was performed; g) a service or proVOL. 94, NO. 6, JUNE 2002

438

HEALTH POLICY

cedure was provided more than once; or h) an unusual event has occured.8 Physicians who use a manual documentation system might conduct more frequent internal monitoring and auditing activities to review billing forms and the application of diagnosis, service, and procedure codes by office staff. When using a billing serv-

ice or electronic claims submission system, physicians might also review computer logs periodically to detect discrepancies in coding and billing patterns. To minimize error rates and maximize claims collection, even small and individual medical practices might benefit from instituting a system of monitoring medical coding and billing practices.

Useful Resources on Medicare Coding and Billinglo

Published by the Centers for Medicare and Medicaid Services * The Medicare Learning Network at www.hcfa.gov/medlearn will provide you with educational
materials and resources on the basics of medical coding and billing. * For assistance with proper coding and billing instructions, visit the Medicare Carrier's Web site at www.hcfa.gov/medicare/incardir.htm. * Contact your Medicare Carrier. The toll free number can be found at http://www.hcfa.gov/ medlearn/tollnums.htm. * Contact Centers for Medicare and Medicaid Services directly regarding coding and billing at doctor11cms.hhs.gov . + Get information on the Medicare Integrity Program at the following Web sites: www.hcfa.gov/ pubforms/83pim/pim83cO 1 .htm or www.hcfa.gov/medicare/mip/mip.rtf. * For more information on Evaluation and Management (E&M) documentation, visit the Web site at www.hcfa.gov/medlearn/emdoc.htm. * View the Office of Inspector General's Compliance Program for Individual and Small Group Physician Practices, at http://oig.hhs.gov/oigreg/physician.pdf.
The OIG recommends using the following applicable statutes and regulations when developing internal procedures for monitoring coding and billing systems: * The official coding guidelines are promulgated by HCFA, now known as the Center for Medicare and Medicaid Services, the National Center for Health Statistics, the American Medical Association and the American Health Information Management Association. + The primary coding systems are: International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM); 1998 Health Care Financing Administration Common Procedure Coding System (HCPCS); and Physician's Current Procedural Terminology (CPT). * There also are several specialized coding systems for specific areas of health care, such as dental procedures, behavioral health benefits and durable medical equipment. + Medical practices should also reference proper documentation guidelines as described in the Documentation Guidelines for Evaluation and Management (E&M) Services, published by HCFA. These guidelines can be found at www.hcfa.gov/medicare/incardir.htm . A number of training materials and resources are available to physicians and their office staff to improve documentation, coding and billing procedures. With adequate training and a compliance plan for monitoring, most medical practices can avoid the pitfalls of improper coding and reduce the risk of revenues lost due to denied claims.
439 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
VOL. 94, NO. 6, JUNE 2002

HEALTH POLICY

Steps to Instituting an Effective Monitoring Program9

1. Develop standards of conduct for office personnel. 2. Implement clear and measurable internal procedures. 3. Implement compliance and practice standards. 4. Conduct internal monitoring and auditing. 5. Conduct appropriate training and education. 6. Develop open lines of communication. 7. Respond appropriately to deficiencies and develop corrective action. 8. Enforce appropriate disciplinary standards when necessary.

revenue loss, calculate financial reserves needed to cover unpaid claims, develop corrective action plans where deficiencies are indicated and institute continuous quality oversight of medical record documentation and service level coding. By conducting a risk assessment and analyzing medical practice vulnerabilities, the physician and office staff can develop management plans for improving processes related to documentation, coding and billing.

Components of Risk Management

Step 1. Risk Assessment Select a random sample of 20 to 40 claims submitted for reimbursement over a three to six month period. Claims selected may be a random sample of all claims submitted or may be selected by type of claims or service codes. Using a sample "clean claim," sample medical record and a checklist, determine the number of elements missing from each selected claims insurance form. Complete a checklist for each selected claim. Using the completed checklists, determine the number of incorrect or incomplete claims submitted; number of billing errors by type of claim, date of service and date of claim submission; number of denials; number of claims resubmissions; and estimated amount of loss in revenues (see Figure 2). Step 2. Risk Adjustment Most health care insurers pay "clean claims" within 30 to 60 business days after receipt of the claim. Using your risk assessment, determine the average time it takes to get your claims paid; number of unpaid claims from the most recent 12-month period; and calculate the amount of cash needed on hand to cover costs incurred but payment not received (IBNR) for the period being reviewed. It should be obvious to the medical practice that "clean claims" allow payers to pay claims accurately within specified timeframes, thereby allowing the physician to maintain a reasonable amount of cash reserves to cover IBNR.

RISK MANAGEMENT
Physicians are better prepared to implement action to assess medical practice vulnerabilities, address concerns regarding medical billing and reduce potential loss of revenue by first understanding documentation standards, coding criteria and reimbursement payment systems.

Managing Risks Associated with Coding and billing

A risk management strategy is recommended as a methodology for analyzing and monitoring medical record documentation, service level coding and insurance billing practices. By incorporating risk management strategies into practice management activities, health care providers may be able to reduce the number of denied claims. Coding and billing should be major components of any provider's compliance program and monitoring activities. While considering quality of medical care for the treatment of patients, physicians should also consider quality oversight of medical practice operations. The OIG suggests "the failure of physician practices to (i) document items and services rendered and (ii) properly submit them for reimbursement is a major area of potential fraudulent or erroneous conduct involving federal health care programs." What can physicians do to reduce the risk of revenues lost due to medical coding and billing errors? We recommend using risk assessment to analyze coding and billing patterns, assess potential
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

References
8. Current Procedural Terminology, CPT Professional Edition, Introduction, "Modifiers." 9. OIG Compliance Program for Individual and Small Group Physician Practices. 10. Medicare and You 2002.
VOL. 94, NO. 6, JUNE 2002
440

HEALTH POLICY

Figure 2.

Claim Number: Insurer/Payer:_ IICD-9 Codes: CPT Codes: HCPCS Codes: Modifiers:

SAMPLE MEDICAL BILLING AUDIT TOOL _____________ Patient Account Number: _ _ ________ ___ Other Insurer/Payer:_ __(1) (2) (3) (4)

(1)
(1)_
-

(2)

(3)

_ (2)_ =_ (3) (4) (2) (1) (3) ___ (4) Check the health insurance claim form being reviewed: [ ] CMS 1500 (formerly HCFA 1500) [ ] CMS 1450 (formerly UB 92)[ ] Other Insurance Form Amount Billed: Claims Status: Denied/Unpaid [ ] Resubmission [ ] Appealed [ ] Please review the insurance form for the following elements: No Yes 1. Is the insured's identification number entered correctly? 2. Is patient's name (last, first and middle) entered correctly? 3. Is patient status box checked? 4. Is the patient's birth date reported as an 8-digit entr 5. Are all health insurance coverage, plans and programs identified? 6. Is the insurance policyholder information complete and correct? 7. Are applicable dates and occurrences of illness or injury entered? 8. Does the claim form identify the rendering physician or provider? 9. Are referring physician's name and ID number present? 10. If applicable, are hospital admission and discharge dates entered? 11. Are ICD-9 diagnosis codes entered in descending order? 12. Is all applicable documentation attached to claim form? 13. Does documentation provide evidence of medical necessity? 14. Are dates of service entered on claim form? 15. Is place of service properly coded on claim form? 16. For prior authorizations, is there a treatment authorization code? 17. Are CPT, HCPCS and modifier codes entered on claim form? 18. Are codes appropriate for level of services provided? 19. Are procedures/services billed at usual and customary charges? 20. Are number of units or mileage for procedures/services entered?

(4)

21. Are third party payments deducted and entered on claim form? 22. Is this a re-submitted claims? 23. If re-submitted, are all partial payments deducted from bill? 24. Is provider's tax identification or social security number present? 25. Is the patient account or control number present and accurate? 26. If applicable, is the facility name, address or ID number present? 27. Does the claim form contain authorized signatures? 28. Are only medically necessary services billed on the insurance form? Amount of unpaid claim Amount recovered from resubmission Amount recovered from appeal Total amount of claim write-off
C) 2002 Adams, Norman, Burroughs To download copies of the CMS 1500 (formerly HCFA 1500) or CMS 1450 (formerly UB 92, HCFA 1450), visit www.hcfa.gov/medicare/edi/edi5.htm
441
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

VOL. 94, NO. 6, JUNE 2002

HEALTH POLICY

Step 3. Corrective Action Plan After determining the level of risk and potential loss, the physician and office staff should sit down and develop corrective action plans to improve medical coding and billing practices. A corrective action plan should: a) Implement procedures to ensure uniform submission of "clean claims"; b) Institute a system for tracking errors in coding and billing; c) Initiate periodic audits of claims; d) Incorporate a system for calculating cash reserves. Step 4. Staff Development and Training One way to reduce errors in medical coding and billing is to provide adequate and appropriate training sessions for office staff. These sessions should be mandatory and periodic (for example, quarterly sessions with records of attendance maintained in personnel files of employees). Contact your Medicare carrier, state Medicaid office, managed care organization and other insurers' provider relations departments and request training for office staff. Step 5. Ongoing Monitoring/Periodic Auditing It is imperative that physicians track their reimbursements and not fully delegate the responsibility to office staff or billing services. Physicians should review all forms relating to billing, finance, authorizations for services, patient consents for release of medical information, policies and procedures with office staff. The OIG recommends periodic review of bills and medical records for compliance with applicable coding, billing and documentation requirements. "The individuals from the physician practice involved in these self-audits would ideally include the person in charge of billing (if the practice has such a person) and a medically trained person (e.g., registered nurse or preferably a physician). Each physician practice needs to decide for itself whether to review claims retrospectively or concurrently with the claims submission." Physicians should be proactive in making necessary changes in management responsibilities, standards, and procedures to protect their medical
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

practice against vulnerabilities associated with medical coding and billing errors. When implementing processes for auditing internal controls and monitoring financial risk, consider the following: Budget Planning. The most important step in business planning is to develop a budget for the coming year. Controlling cost is a critical step in the survival of a business and good budgeting provides a framework for modifying cost overruns. Planning a budget based on actual financial reports provides a small business owner or manager a starting point for taking action to control costs. The difference between actual and budgeted numbers is called a variance and could mean a problem that requires immediate attention to stop unnecessary hemorrhaging of funds. Developing a budget requires these four essential steps: 1. Determining the flow of information from top-down or bottom-up staff involvement. 2. Deciding what will be measured and tracked. 3. Gathering historic data on sales trends, volume of office or hospital services, office procedures and testing. Gather information on expenses related to direct costs (labor, supplies), indirect costs (general and administrative expenses), fixed costs (rent and depreciation) and variable costs (includes many of the direct cost of doing business, such as taxes and energy). 4. Making projections for the coming year. This will depend on the use of incremental vs. zero based or hybrid budget forecasts as well as industry trends and prevailing economic conditions. Organizational Responsibilities. Is there an up-to-date organizational chart that adequately portrays individual responsibilities and reporting relationship? Data Processing. Does the entity use electronic data processing (EDP) or a billing contractor for any of its billing operations? General Accounting. What are the components of a basic General Accounting System in a Physician s Office? Doctors have become increasingly aware of their roles as managers of their own health care businesses. In addition to proper codVOL. 94, NO. 6, JUNE 2002
442

HEALTH POLICY

ing and billing for services, the degree to which they fail or succeed is contingent upon their understanding of the cycle of finance in their offices. Accounting is the language in which financial transactions are recorded and, as such, prompts some familiarity with its basic terms, concepts and applications. Accounting also is a set of rules that govern how businesses record transactions and detail the things that they own and owe. It forces businesses to measure things in a consistent way. This, in turn, allows the comparison and assessment of a company's health relative to its competitors, as well as a projection of its value for potential buyers or creditors. The three most important terms of accounting are 1) assets, 2) liabilities and 3) shareholder equity.
What is an asset? An asset is something of value that is useful to the company and that was acquired at a measurable cost. There are two categories of assets: fixed assets, and current assets. Fixed assets are those that will not be liquidated or converted to cash in the normal course of business (plant, property and equipment). Current assets are those assets that will be converted to cash in the course of business, usually in less than one year (receivables and inventory). An account receivable is a means for companies to keep track of money they are owed. This is driven by the rules of accrual accounting. Accrual accounting states that businesses can consider a service or product sold once the service is provided or the merchandise is shipped. The company does not have to wait until payment for the services or goods is received. The company, thus, establishes a paper asset on its books-called an account receivable-to represent cash until actual payment is received.

liabilities, which must be met in less than one year, and long-term liabilities. An account payable is a way for businesses to keep track of money they owe. It is also driven by the accrual method of accounting. Under accrual accounting, a transaction takes place when the company receives a product, not when it pays for the product. By incurring a liability you must balance your books by creating a paper liability called "account payable." This represents the amount of money you owe until it is paid.
What is shareholder equity? Shareholder equity is another way of describing a company's net worth. It is calculated by taking a company's assets and subtracting liabilities. Net worth = assets minus liabilities Assets = liabilities plus net worth This is called the basic equation of accounting and it must balance.

TRACKING ASSETS, LIABILITIES AND NET WORTH

There are several steps businesses take to track their assets, liabilities and net worth: a) Maintain a daily record of transactions as they occur. This is called ajournal or diary. b) Simultaneously, maintain separate ledgers, which are individual accounts for each category of assets (cash, inventories and account receivables) and liabilities (wages payable and accounts payable). c) Each time a service is rendered or a product is sold or bought, it is recorded in the running daily journal. d) Transcribe the same daily information into the affected individual accounts. This is called posting. e) Transcribe the activity that has taken place in the individual account-called a general ledger This combines the results of all individual accounts. The general ledger is usually referred to as the company of books.
VOL. 94, NO. 6, JUNE 2002

What is a liability? A liability is an obligation that the business will have to meet (payroll, taxes and the cost of supplies). There are two types of liabilities: current
443 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

HEALTH POLICY

ASSESSING FINANCIAL HEALTH AND PERFORMANCE

Businesses utilize three key financial statements to access their financial health and performance: a) The balance sheet is used to illustrate the business' overall financial position based on what it owns (assets), what it owes (liabilities), and what assets remain after covering its liabilities. It best measures the business level of risk. b) The income statement shows the net income (net profit) or net loss for a specified period of time. It is also called "profit and loss statement" and is the best indicator of business profitability. c) The cash flow statement indicates how cash has flowed into and out of a company's accounts during a specified time period. This is the best indicator of a business' financial activity. Does the general accounting system have these characteristics? 1. A descriptive chart of accounts and efficiency account coding system? 2. Simply arranged ledgers, which permit statements to be prepared directly from the books without analysis or reclassification? 3. Standard journal entries and journal entry numbers? 4. Are all journal entries reviewed and approved by a responsible employee? 5. Have all adjusting journal entries arising from the most recent independent audit been recorded on the books? 6. Do the budgets and projections lend themselves to effective comparison with actual results? 7. Are material variances reviewed and explained? 8. Are monthly comparative financial statements prepared so that they are sufficiently informative to highlight abnormalities? 9. Are the books of original entry posted promptly and the general ledger and subsidiary ledgers kept current and balanced periodically? 1O.Are there adequate safekeeping facilities for custody of the accounting records such as fireproof storage areas and restricted access cabinets?
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

ACCOUNTS RECEIVABLE
Does the medical practice carry fee-for-service receivables on its books? 1. Are detailed records maintained for all receivables and reconciled to the general ledger monthly? 2. Are procedures adequate to ensure that services performed on a fee-for-service basis are billed? 3. Are procedures in place for proper balance billing (the amount owed by patients against charges once insurance payments are received and recorded) for office services, as well as hospital services? 4. Is a numerical control maintained over charge slips? 5. Are receivables reserved to provide for anticipated reductions to a usual and customary rate or Relative Value Scale (RVS)? 6. Is an aging of accounts receivable prepared on a monthly basis? 7. Is the write-off of uncollectable accounts receivable approved by the physician or responsible official? 8. Are differences between amounts billed and actual amounts received promptly coded and reconciled? 9. Do balance sheet adjustments resulting from payment reconciliation require approval of the physician or responsible official prior to recording in the general ledger? Does the medical practice participate in capitated health care plans? 1. Are capitated payments reconciled with the number of paneled members per month? 2. Are co-payments properly entered in the daily ledger? 3. Are procedures in place to track billing for unpaid co-payments? 4. Are procedures in place to track bonuses or withholds due from the managed care organization? Does the medical practice provide medical services to uninsured (selfpay) patients? 1. Are standards in place to promote payment at time of visit? 2. Are procedures in place for tracking and
VOL. 94. NO. 6. JUNE 2002
444

HEALTH POLICY

billing payments made at time of visit? 3. Do you offer discounts to uninsured patients?

CONCLUSION
Whereas, health care spending in the United States is steadily increasing, reimbursements to physicians may be declining. As stated earlier in this article, there are several factors contributing to increased spending in the health care industry and decreased reimbursements to physicians. While physicians may be providing more costly health care services, they may not be getting paid what they deserve from insurers. Inadequate medical record documentation, inappropriate service level coding and inaccurate billing may be putting some medical practices at risk of financial loss, exclusion from government contracts, and investigation for fraud and abuse. By conducting monthly, quarterly, and annual monitoring and auditing of internal controls to assess financial risk, physicians can project potential financial gains and losses. The aforementioned questions regarding organizational responsibilities, data processing, general accounting, assets, liabilities, net worth, accounts receivable, accounts payable, purchasing, and financial performance will assist the medical practice in determining financial risk. By considering budget planning, physicians can acquire a better understanding of their financial operations and not leave to chance the financial future of their businesses. Many physicians now participate in capitated managed care plans and may be losing additional revenue. In addition to not being fully reimbursed for fee-for-service claims, physicians may also be losing revenue on their managed care contracts. A significant amount of revenue is lost to the managed care plans when physicians neglect to collect and track co-payments from patients for services due at the time of service. Although small individually ($5-25), in aggregate, these co-payments account for a large annual receivable. Physicians should carefully negotiate their own managed care contracts and not fully delegate this responsibility. As each managed care contract is different, office staff should be educated on the terms and conditions of each contract to ensure that co-payments and other applicable fees are collected and recorded at the time of service.
VOL. 94, NO. 6, JUNE 2002

ACCOUNTS PAYABLE
(Money owed to creditors for goods or services already received.)

Purchases
One area of loss for physicians' offices is in purchasing and receiving goods and services from vendors. Controls must be established on the outflow of cash from accounts without supervision and the full knowledge of senior management. The mandatory use of a voucher system and properly processed invoices provides more internal control. A written receiving slip on all materials received from vendors will obviate duplicate invoices and allow easier handling of returned items. All vouchers and invoices must be reconciled monthly with the account payable ledger and subsequently the general ledger.

Are formal written purchase orders requiredfor all purchases (at least all those in excess of relatively small amounts)? 1. Are written receiving reports prepared on all materials received? 2. Are such receiving reports numerically controlled? 3. Is an accounts payable trial balance taken and balanced to general ledger control at least monthly? 4. Are monthly statements from vendors regularly reconciled to open vouchers or accounts payable ledgers? 5. Are advance payments to vendors set up as receivables? 6. Are returned purchases controlled in a manner to ensure that vendors will be charged accordingly? 7. Is there an adequate record of open purchase orders and commitments? 8. Is there written evidence that invoices have been properly processed (i.e., a block stamp, attachment of a voucher, etc.) before payment? 9. Are duplicate invoices conspicuously stamped or destroyed as a precaution against duplicate payment?
445
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

HEALTH POLICY

Several initiatives have been initiated at the federal and state level in recent years to assist health care providers with getting paid for medically necessary services. The Department of Health and Human Services, Center for Medicare and Medicaid Services, and Office of Inspector General have implemented new initiatives in recent years to assist providers with understanding Medicare billing procedures and claims submission processes. State Medicaid programs have issued new regulations on health care billing procedures. Several states have enforced laws aimed at protecting physicians from managed care plans and other insurers who do not pay claims in a timely manner. However, the responsibility for timely and accurate submission of medical bills lies within the medical practice. It is important for physicians to remain up-to-date with new health care regulations, coding criteria, medical record documentation standards, billing requirements, guidelines for health care financing and reimbursement payment systems. Physicians sometimes choose to delegate the responsibility of billing to office staff or billing services. Improper and erroneous claims may be submitted for reimbursement without the physician's knowledge. The decision to delegate billing responsibilities could be costly for the medical practice and could result in loss of revenue, financial penalties and disciplinary action when erroneous billing occurs. It is essential that physicians submit clean claims to government and private health care payers in order to collect the maximum reimbursements possible for medically necessary services and avoid unnecessary audits and utilization reviews. We acknowledge that the task of monitoring business practices is an added responsibility for physicians, but to do otherwise would be poor business management. Health care and business analysts suggest that physicians may not be getting the reimbursements they deserve, due in part to inadequate oversight of medical record documentation, coding and billing practices. Given today's health care compliance environment, prevention of improper medical billing is the desired result for physicians. It also makes sound
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

business sense. To achieve the desired result, this article recommends adoption of compliance and risk management strategies for monitoring medical practice standards and assessing financial risk. By scrutinizing billing patterns and intensifying financial acuity, the medical practice can reduce its number of unpaid claims, thereby improving its cash flow.
The National Medical Association k Office of Health Policy is interested in the opinions of NAM members regarding Evaluation and Management (E&M) coding. It appears that E&M coding tends to be problematic for physician practices in the areas of compliance and revenue generation. To assist the Health Policy Office in addressing the needs of members, a survey on coding challenges facing the medical practice will be conducted in August 2002 at the NM4 Scientific Convention in Honolulu, Hawaii.

ABOUT THE AUTHORS

Diane L. Adams, MD, MPH is director of health policy, research and professional affairs at the National Medical Association, Washington, D.C. She also is a member of the American Medical Association, CPT editorial panel evaluation and management workgroup. Helen Norman, MA is a compliance officer for the managed care division of Santa Clara Valley Health and Hospital System, San Jose, CA. Valentine J. Burroughs, MD, is chair of the Health Policy Committee for the NMA Board of Trustees. He is a practicing board certified endocrinologist and internist in New York City and is the medical director of Health Care New York IPA and associate medical director at Group Health Insurance of New York.

REFERENCES
Jacob J A. Losing proposition: When doctors take in less than what goes out. American Medical News. Jan. 7, 2002, wwwamaassn.org/sci-pubs/amnews/pick 02/bisaO I 07.htm. US Department of Health and Human Services, Audit Shows Sustained Drop in Improper Medicare Payment. HHS News. March 6,2001, wwwwhhs.goy/ntw_ 0010306wtml.
VOL. 94, NO. 6, JUNE 2002 446

HEALTH POLICY

(References continued)
National Coalition on Health Care, Facts on the Cost of Health Care. www.nchc.org/cost.html . National Coalition on Health Care, Did You Know? Health Care Facts: What You Need to Know, Health Care Spending. December 1998 www.nchc.org/know/index.html . US Census Bureau, Public Information Office, Federal Domestic Spending Up 6 Percent in 2000; Five States Received One-Third of All Funds. Census Bureau Reports. United States Department of Commerce News,April 18, 2001, wwwcensus.gov/Press-Release/www/2001/cbOl-73.html . The Cost of Health Care. Inside DUMC 2000. March 20, 2000, vol. 9, no. 6. Duke University Medical Center Office of Publications, www.inside.mc.duke.edu/. Compliance Program Guidance for Individual and Small Group Physician Practices. Federal Register Vol. 65, no. 113, or http://oig.hhs.gov/authorities/docs/cpgphysiciandraft.pdf. PM&R Resources, The Physical Medicine and Rehabilitation Specialist, Medical Coding & Reimbursement, Correct Coding Helps You Get Paid, www.phvsiatrists.com/ index.php?option=news&Itemid=2. Kongstvedt PR, The Managed Health Care Handbook. Aspen Publication, Gaithersburg, MD, 2001. Rakich JS, Longest BB Jr, Darr JD, (1992), Managing Health Care Organizations. Health Professions Press, Baltimore, MD, 1992. Gapenski LC. Understanding Health Care Financial Management, 2nd Ed. AUPHA Press/Health Administration Press, Chicago, Illinois, 1996. Ward WJ. Health Care Budgeting & Financial Management for Non-Financial Managers, Auburn House, Westport, CN, 1994. Health Care Financing Administration (HCFA). Overview of Medical Review (MR) and Benefit Integrity (BI) and Medicare Integrity Program-Provider Education and Training (MIP-PET) Programs. Medicare Program Integrity Manual, Ch.l. www.hcfa.gov/pubforms/83 nim/pim83c0l.htm. Health Care Financing Administration (HCFA). Paper Forms and Instructions, www.hcfa.gov/medicare/edi/edi5.htm . Department of Health and Human Services (DHHS), Health Care Financing Administration (HCFA). Program Safeguard Contractor Statement of Work. Online at

We Welcome Your Comments

The Journal of the National Medical Association welcomes your Letters to the Editor about articles that appear in the JNMA or issues relevant to minority health care. Address correspondence to Editor-inChief, JNMA, 1012 Tenth St., NW, Washington, DC, 20001; fax (202) 3711162; or e-mail ktaylorgnmanet.org .

www.hcfa.gov/MEDICARE/MIP/finalsow.htm. hcpro"s complianceinfo.com, Ten points of OIG concern. Source: Physician Practice Compliance Report, www.compianceinfo.com/howto/oigconcernPPCR.cfin.
American Medical Association, Current Procedural Terminology, CPT 2000, Prof. Ed. 1999, CPT Intellectual Property Services, Chicago, IL.

447 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

VOL. 94, NO. 6, JUNE 2002