Creating a ‘Coding’ Compliance Plan

Vol. 11 •Issue 18 • Page 13
Creating a ‘Coding’ Compliance Plan

A vital part of a health care facilities’ corporate compliance program is a “coding” compliance program. Having an effective coding compliance program shows the government that the facility is genuinely concerned about correct coding and billing and that a plan is in place to identify and correct any coding and/or billing inconsistencies that may arise. The creation of a formal Standards of Conduct policy that fits your organization’s individual needs is the first step to an essential part of a coding compliance program. This is advisable because creating a formal Standards of Conduct policy is a component included in the Department of Health and Human Services’ (HHS) Office of Inspector General’s (OIG) model compliance program.

A Standards of Conduct document should include a summary of the institution’s basic philosophy and policies, a general outline of coding procedures and a confidentiality statement. This document should be concise and comprehendible. As part of the coding compliance program, coders should be required to sign a statement annually indicating that they have read, understand and agree with the Standards of Conduct. It would also be advantageous if the Standards of Conduct were posted in a place where everyone in the department would have a chance to read them.

The Standards of Conduct is only one portion of a coding compliance program. The program itself should outline coding procedures in detail, showing how your coders maintain correct coding and ensure the medical record supports the CPT and ICD-9 code(s) billed. It should be clear throughout the program that not only the coders, but also the physicians (and ancillary providers) play a primary role in coding compliance. If your facility does not have a coding and documentation education/training program, it would be highly advisable to create one or hire a consultant (annually or on an ongoing basis) to hold seminars on documentation guidelines and procedure/diagnosis coding. The coding compliance program should note that the facility has such a program for physicians as well as for coders.

The plan should also provide guidelines for correspondence between physicians and coders. Facilities need to make sure that physicians are available for coders’ questions. This should not be perceived as a “you’re wrong and I’m rightÉ” situation, but “help me understandÉ”. Having open lines of communication can also provide education for the physician and coder.

Additionally, a good coding compliance program includes regular auditing by an objective professional, such as having an internal auditing department. This should consist of a group of highly specialized, educated coders with extensive experience. The procedures for such types of audits should be outlined in the program.

Perhaps more importantly, though, is what the facility does with the results of those audits. If the audit shows any type of non-compliance, steps should be taken to assure that the facility is trying to correct the offense, for example, by education, disciplinary actions and/or refunding overpayments. The facility should show that they have taken all reasonable steps to assure they have responded appropriately to the offense and that they are trying to prevent further offenses and legal liability. This, too, is something that the government may take into consideration if or when it comes time to determine penalties. It is possible that the facility will receive penalty reductions if an offense occurred “despite an effective program to prevent and detect violations of law,” according to the U.S. Sentencing Guidelines.

Furthermore, the coding compliance program should indicate that there is someone who performs compliance oversight, whether it be a compliance officer or a committee. This person (or persons) would oversee the audits, monitor compliance issues and train employees in compliance matters.

As the government is becoming more involved in health care, now is the time to establish compliance programs for your facility. Establishing and maintaining a coding compliance plan will help physicians and coders in avoiding activities that could be targeted as fraud and abuse and by ensuring that their claims cannot be categorized as being fraudulently submitted. n

Nancy M. Hall is with the Watson Clinic, LLP, in Lakeland, FL.

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