Coding Compliance: Every Facility Should Aim fo

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COMPLIANCE IS A MAJOR TOPIC IN JUST ABOUT EVERY HEALTH CARE journal, health information management (HIM) publication and Internet list-serve. Why is compliance such a hot topic? It’s not really new to anyone working in health care, as hospitals have been aware of, and for the most part, complying with all Health Care Financing Administration (HCFA) and other regulatory requirements related to good coding and billing practices for some time now.

By Doreen Swadley,MA,RRA,CHE

What makes compliance such a compelling and serious issue–monetary penalties aside–is that HIM professionals have worked long and hard to understand the issues that are the focus of Office of Inspector General (OIG) investigations, including upcoding and DRG creep. We are caught between the gray area of voluminous coding rules/guidelines and the day-to-day application of these rules. We are trying to apply these rules to medical records that contain patient care documented by multiple care providers who speak the language of their clinical specialty, which we all know is not always the language used by coders.

Our job as HIM professionals is to continue our coding training, education and quality assessment, but to move it to a framework that is much more proactive and uses more concurrent performance improvement techniques as a way to continually improve overall coding accuracy.

How should HIM departments approach this? Should they put together a coding compliance plan? What form should the plan take? What form should physician education take? All these questions are currently being asked by HIM professionals.

Mainline Health System, which consists of three acute care hospitals in the Philadel-phia area, initiated several activities that bring HIM closer to understanding what compliance means for day-to-day coding activities and how it will relate to the system’s overall compliance efforts.

Mainline Health has had a compliance department since early 1997. A system-wide compliance committee has started to address communication issues–how the compliance message should be conveyed to the rest of the organization and how particularly sensitive areas like coding and billing will be handled. As the corporate director of HIM at Mainline Health, I am a member of that committee.

Things to Know About Compliance

What kind of compliance plan should HIM departments have in place? Before any plan can be developed, HIM professionals should be familiar with a few issues surrounding the compliance environment. Here are some things that Mainline Health is doing in this area.

* HIM departments at Mainline Health had been without management and coding support for awhile. Recently, a system-wide manager for data quality and reimbursement was hired. This is one area where system-wide leadership is critical. All HIM coders will receive consistent training regarding coding, documentation and compliance issues.

* HIM directors should get and become familiar with the OIG work plan for FY98 and the new Model Compliance Program for hospitals. The work plan briefly explains all the projects that they “may” focus attention on for FY98. You can get the work plan and other OIG information at

Some recent reports have stated that the OIG will be looking at DRG 416 vs. DRG 320 (Sepsis vs. UTI) and DRG 127 vs. DRG 475. These last two DRGs center on how codes are sequenced for patients admitted for respiratory failure due to congestive heart failure. DRG 475 pays about three times more than DRG 127, which gives the OIG a financial incentive for pursuing this DRG pairing.

* The OIG work plan is not an exhaustive list of what the government might want to look at with regard to compliance. State U.S. Attorney offices may have their own work plans that include areas to investigate that are not mentioned in the OIG plan. However, it is my understanding that U.S. Attorney plans are confidential information and not available to the public.

* In an attempt to quantify what codes and/or DRGs might represent a compliance problem, do not do retroactive record reviews to get the information you are looking for. If you find any compliance issues by doing a retroactive review, the law requires that this information be reported to the OIG and any overpayments to your facility will then need to be paid back. Before you do any kind of record review, consult your compliance department, or if you don’t have one, your legal counsel.

* How do you find out where any problem areas are? Ask your in-house experts, your coding staff, what areas/services are difficult to code or have chronically poor physician documentation. Also, look at DRGs that fall into the with/without CC pairings. The OIG is currently looking at pneumonia DRGs 079 and 089, and one of the other items in their FY98 work plan is DRG creep. I believe these two work plan items are a good clue as to where they may look next. Also, look at DRG groupings that represent high volume/mission critical clinical services for your organization.

* Coding compliance isn’t just related to DRGs, although that is what the OIG is currently focusing on. Don’t forget hospital-based outpatient services and things that are “hardcoded” through your chargemaster. As CPT codes are being assigned through the chargemaster, is the documentation in the record supportive of them? Prime areas that come to mind are catheterization labs, endoscopy suites, etc.

* Only do concurrent record review after you have isolated codes, services or DRGs that might have a compliance issue. By concurrent I mean after coding, but before billing. Not only must the coding be reviewed to make sure it is accurate, but the documentation sources of the codes need to be understood. Remember the HIM mantra: if it isn’t written down [by the physician] it didn’t happen, and it can’t be coded and billed.

Coding Compliance Plans

At Mainline Health our coding compliance plan is part of our Coding Policy and Procedure Manual, which is known as our reference guide. Our reference guide’s first page is the American Health Information Management Association’s (AHIMA) Standard of Ethical Coding. The compliance part of the guide includes documentation from coder education and training sessions, as well as coding quality assessment activities, results and action plans.

Our entire approach to coding compliance is not to develop a new set of coding guidelines or plan, but to add more on-going performance improvement to the process. Our goal continues to be 100 percent coding accuracy. We will also be conducting monthly training, education and round robin record review sessions among the coders.

HIM will also play a key role in developing and implementing physician education sessions, which will be part of Mainline Health System’s overall physician education efforts. Physician participation in educational programs that focus on coding and documentation are something that should be emphasized by hospitals according to the OIG Model Compliance Program for Hospitals.

Doreen Swadley is corporate director of health information management for Mainline Health System, which consists of three acute care hospitals within the Philadelphia area Jefferson Health System.

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