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  CPT 101 - Understanding Billing Fraud & Manipulation

This text is intended to familiarize claims and investigative personnel with the best weapon available in the fight against billing fraud - Current Procedural Terminology or "CPT" - the Bible for healthcare billing.

The reader is introduced to the concept of CPT and other billing manuals based on CPT, how they were intended to be used, how they are abused, specific fraudulent schemes based on CPT, red flag indicators of billing fraud and how to defend against it.

If you don't understand CPT now, you will when you finish this training manual.

Written by Eric Tackett
Published by the California Investigative Academy


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Table of Contents

Chapter 1 Introduction to Billing Codes
Chapter 2 Understanding CPT
- CPT Construction & Content
- The Purpose of CPT
- Evaluation Management (E/M Codes)
- Radiology Codes
- Physical Medicine Codes
- Other Commonly Abused Sections of CPT
Chapter 3 Common Forms of Billing Fraud & Abuse
- False Billing
- Upcoding
- Downcoding
- Unbundling
- Rebundling
- Diagnostic Frauds
- "Exotic" Codes
-Other Forms of Billing Fraud
Chapter 4 Indicators of Billing Fraud
- Reviewing the HCFA 1500 Form
- Reviewing Itemized Invoices/Statements
- CPT vs. ICD-9
- Mutually Exclusive Codes
- Other Indicators of Fraud
Chapter 5 Defending Against Billing Fraud
Chapter 6 Summary
Chapter 7 Resources

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