When is the last time your hospital, health system or organization looked at codes and clinical documentation to ensure everything was compliant with law and best practices?
If revenue cycle teams are struggling to answer that question, it might be time to review the formal coding compliance policy.
Coding, billing and collections are vital today not only from a revenue perspective, but also from a compliance perspective. Earlier this year, the Center for Public Integrity unleashed an investigative report showing medical billing abuse and upcoding may have cost Medicare $11 billion over the past decade. In addition, the HHS Office of Inspector General said provider billing practices will be a major area of focus within its 2013 work plan.
"The collection of accurate and complete coded data is critical to healthcare delivery, research, public reporting, reimbursement and policy-making," said Bonnie Cassidy, a health information management executive with Nuance Communications, past president of AHIMA and author of a recent coding compliance whitepaper. "The integrity of coded data and the ability to turn it into functional information requires all users to consistently apply the same official coding rules, conventions, guidelines and definitions."
Here, Ms. Cassidy outlines three steps hospitals and health systems must take with their coding compliance policies, which may not have been touched in months or even years.
1. Look at the current coding compliance policy, and ensure it has certain, requisite components. Before a hospital can revamp its coding compliance policy, it first must acknowledge a basic coding principle: that all HIM staff and coding professionals will only report "the codes that are clearly and consistently supported by authenticated clinical documentation in accordance with code set rules and guidelines," according to Ms. Cassidy.
With that as a guide for a coding compliance plan, Ms. Cassidy recommends the following components be included in the planning phase:
• A general policy statement about that commitment to assign and report codes correctly
• A specific outline of the policies and procedures that apply to certain locations and care settings (e.g., emergency department)
• Government- and payor-specific reporting requirements
• A method for coding new procedures or unusual diagnoses as well as a section that identifies areas of coding risks that have popped up in audits
• In light of the increased focus on past upcoding in the sector, a statement that specifically clarifies codes will not be assigned, modified or excluded solely for the purpose of maximizing reimbursement or avoiding reduced payment
Ms. Cassidy said there are several other processes to be included, such as procedures to identify optional codes for statistical purposes and procedures for submitting claim rejections. Having a simple, uniform coding compliance policy that all coders and revenue cycle staff can understand is the ultimate end-goal, though.
2. Define coding and clinical documentation guidelines for six primary areas. Ms. Cassidy laid out six main areas where coding procedures and processes must be reviewed.
• Inpatient coding. Inpatient coding is one of the biggest and most important areas when it comes to a hospital's coding compliance policy. Ms. Cassidy said a good first step is to sync patient face sheets, which show the patient's diagnoses and complications, with the electronic health record. Other critical coding and clinical documentation guidelines for the inpatient side include coding reviews of progress notes, patient history, discharge summary, consultation reports, operative reports, pathology reports, lab reports, radiology reports, physician orders and nutritional assessments.
• Outpatient coding. Outpatient coding will be a major factor in the future as hospitals' outpatient volumes generally continue to rise. Hospitals should consider the following clinical documentation areas for the outpatient coding portion of their compliance policy: authenticated physician orders for services, clinician visit notes, reasons why the service was ordered, test results, therapies and medications. Hospitals should also review coding guidelines that are specific to outpatient diagnostic services and outpatient therapeutic services.
• Ambulatory surgery coding. Hospitals that want to update their ambulatory surgery coding procedures should have coders look at five specific parts: patient history and physician, results of prior diagnostic tests, operative report, pathology report and medications.
• Observation record. When it comes to observation records (e.g., for evaluation and management stays), Ms. Cassidy said coders must be diligent in their review of the patient's history and physician, the physician orders for admission/treatment and all other clinical observations, notes and summaries.
• Emergency department coding. Clinical documentation areas in the ED that coders should review are the ED report, initial encounter, diagnostic interventions, treatment interventions and nursing notes, among others.
• Computer-assisted coding. CAC, which is the use of computer software to generate medical codes based on clinical documentation from physicians and other providers, is still an "unknown technology," Ms. Cassidy said. While there are long-term benefits of CAC, such as improved productivity and coding accuracy, hospital executives must ensure CAC systems are built through a collaborative effort with HIM at the helm.
3. Review and/or update the coding compliance policy at least once per year. It does not matter if a hospital's medical records are paper-based, electronic or in some type of hybrid phase — coding compliance policies must be reviewed at least once per year. There are a bevy of coding guidelines and updates every year, and waiting any longer than 12 months to review and update the policies may cost the hospital financially and may go against the hospital's mission to provide the best clinical care possible.
If revenue cycle teams are struggling to answer that question, it might be time to review the formal coding compliance policy.
Coding, billing and collections are vital today not only from a revenue perspective, but also from a compliance perspective. Earlier this year, the Center for Public Integrity unleashed an investigative report showing medical billing abuse and upcoding may have cost Medicare $11 billion over the past decade. In addition, the HHS Office of Inspector General said provider billing practices will be a major area of focus within its 2013 work plan.
"The collection of accurate and complete coded data is critical to healthcare delivery, research, public reporting, reimbursement and policy-making," said Bonnie Cassidy, a health information management executive with Nuance Communications, past president of AHIMA and author of a recent coding compliance whitepaper. "The integrity of coded data and the ability to turn it into functional information requires all users to consistently apply the same official coding rules, conventions, guidelines and definitions."
Here, Ms. Cassidy outlines three steps hospitals and health systems must take with their coding compliance policies, which may not have been touched in months or even years.
1. Look at the current coding compliance policy, and ensure it has certain, requisite components. Before a hospital can revamp its coding compliance policy, it first must acknowledge a basic coding principle: that all HIM staff and coding professionals will only report "the codes that are clearly and consistently supported by authenticated clinical documentation in accordance with code set rules and guidelines," according to Ms. Cassidy.
With that as a guide for a coding compliance plan, Ms. Cassidy recommends the following components be included in the planning phase:
• A general policy statement about that commitment to assign and report codes correctly
• A specific outline of the policies and procedures that apply to certain locations and care settings (e.g., emergency department)
• Government- and payor-specific reporting requirements
• A method for coding new procedures or unusual diagnoses as well as a section that identifies areas of coding risks that have popped up in audits
• In light of the increased focus on past upcoding in the sector, a statement that specifically clarifies codes will not be assigned, modified or excluded solely for the purpose of maximizing reimbursement or avoiding reduced payment
Ms. Cassidy said there are several other processes to be included, such as procedures to identify optional codes for statistical purposes and procedures for submitting claim rejections. Having a simple, uniform coding compliance policy that all coders and revenue cycle staff can understand is the ultimate end-goal, though.
2. Define coding and clinical documentation guidelines for six primary areas. Ms. Cassidy laid out six main areas where coding procedures and processes must be reviewed.
• Inpatient coding. Inpatient coding is one of the biggest and most important areas when it comes to a hospital's coding compliance policy. Ms. Cassidy said a good first step is to sync patient face sheets, which show the patient's diagnoses and complications, with the electronic health record. Other critical coding and clinical documentation guidelines for the inpatient side include coding reviews of progress notes, patient history, discharge summary, consultation reports, operative reports, pathology reports, lab reports, radiology reports, physician orders and nutritional assessments.
• Outpatient coding. Outpatient coding will be a major factor in the future as hospitals' outpatient volumes generally continue to rise. Hospitals should consider the following clinical documentation areas for the outpatient coding portion of their compliance policy: authenticated physician orders for services, clinician visit notes, reasons why the service was ordered, test results, therapies and medications. Hospitals should also review coding guidelines that are specific to outpatient diagnostic services and outpatient therapeutic services.
• Ambulatory surgery coding. Hospitals that want to update their ambulatory surgery coding procedures should have coders look at five specific parts: patient history and physician, results of prior diagnostic tests, operative report, pathology report and medications.
• Observation record. When it comes to observation records (e.g., for evaluation and management stays), Ms. Cassidy said coders must be diligent in their review of the patient's history and physician, the physician orders for admission/treatment and all other clinical observations, notes and summaries.
• Emergency department coding. Clinical documentation areas in the ED that coders should review are the ED report, initial encounter, diagnostic interventions, treatment interventions and nursing notes, among others.
• Computer-assisted coding. CAC, which is the use of computer software to generate medical codes based on clinical documentation from physicians and other providers, is still an "unknown technology," Ms. Cassidy said. While there are long-term benefits of CAC, such as improved productivity and coding accuracy, hospital executives must ensure CAC systems are built through a collaborative effort with HIM at the helm.
3. Review and/or update the coding compliance policy at least once per year. It does not matter if a hospital's medical records are paper-based, electronic or in some type of hybrid phase — coding compliance policies must be reviewed at least once per year. There are a bevy of coding guidelines and updates every year, and waiting any longer than 12 months to review and update the policies may cost the hospital financially and may go against the hospital's mission to provide the best clinical care possible.
More Articles on Hospital Coding Compliance:
How Comprehensive Clinical Documentation Improvement Pulls ICD-10 Projects Together
5 Cornerstones of a Culture of Compliance for Hospitals
Is Your Technology Ready for ICD-10?