Medical Billing and Coding expert witness must possess a thorough understanding of several factors and be comfortable providing oral and written testimony for depositions, expert reports and trial appearances in court.
Establishing a baseline for usual customary and reasonable (UCR) costs for care starts with an evaluation of the clinical documentation and coding. An expert witness may use
this type of analysis may be required in personal injury cases, class actions, workers compensation, fraud and false claims act litigation, life care plans in medical malpractice, or other engagements. Several factors may be considered including:
- Inpatient procedure
- Outpatient procedure
- CPT codes for outpatient procedures
- ICD-9 codes for diagnosis and inpatient procedures
- ICD-10 codes for diagnosis and inpatient procedures
- DRGs (diagnosis related groupings) used in the Inpatient Prospective Payment System (IPPS)
- Hierarchical condition codes (HCCs) used in risk adjustment for Medicare Advantage (Medicare Part C) or Accountable Care Organizations (ACOs)
- Relative value units (RVUs) in diagnostic imaging or the Outpatient Prospective Payment System (OPPS)
- Geographic analysis
- Medical necessity
- Prior authorizations
- Guidance from Medicare Administrative contractors.
A competent expert witness must be capable of using state and federal statutes, guidelines and industry best practices in these areas to support their opinions.