Chapter 1.2 : Procedure Coding, Reimbursement, and Billing Compliance

Abstract:

The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services issued compliance program guidance for clinical laboratories in August 1998 ( 1 ). This anti-fraud and -abuse document addresses Medicare and Medicaid program integrity, with emphasis on issues such as coding and billing; medical necessity; sales and marketing; arrangements with outside providers, suppliers, and vendors; and auditing and monitoring. While published more than 15 years ago, this program guidance remains highly relevant in today’s laboratory medicine environment, as the Patient Protection and Affordable Care Act of 2010 mandates the establishment of a compliance program by all health care providers ( 2 ). Every clinical laboratory should be committed to doing business with any client, governmental or private, in an ethical, fair, honest, and trustworthy manner. While this document covers principles laid out in the federal compliance program guidance, each laboratory compliance program must be customized to be compatible with the overall institutional compliance program.