Preparing for PEPP: What HIM Professionals Can Do
An old proverb states, “If you know you’re going to have company, clean your house first.”
Never is this proverb more aptly applied than when used in reference to HCFA’s Pay-ment Error Prevention Program (PEPP). There is a lot that health information management (HIM) professionals can, and should, do to prepare their departments for a possible audit by their state’s peer review organization (PRO). Below are some suggestions.
* Review the PEPP criteria provided by your state’s PRO. Every PRO will provide to the medical facilities in its state a set of criteria that will serve as the basis for PEPP-related audits. “Every member of the HIM department should review these criteria carefully,” said Tim Cuerdon, the director of HCFA’s priority management and evaluation division within the quality improvement group. “If there’s any confusion about what the criteria mean or how it will be carried out, call the PRO for an explanation–that’s what they are there for.”
* Create an internal compliance program (if you don’t already have one). Your facility doesn’t have a compliance program or a compliance officer? “Talk to someone in your facility’s administration about this–if you don’t have such a program, you should know why,” said Lance Coss, a health care analyst and the PEPP coordinator for HealthInsight, a PRO headquartered in Utah. “Perhaps your facility has an external auditor.”
If your facility does have a compliance program, re-evaluate it. “Add in some audits that will target documentation from all of the different types of health care professionals in your facility,” said Lucia Hammer, director of Medicare review and PEPP for the Colorado Foundation for Medical Care (CFMC), Colorado’s PRO. “Perform some internal audits of your state’s targeted DRGs. After PEPP begins, internal audits will be required…so facilities might as well begin doing them now.”
* Review “the basics” of coding with all HIM staff members. “The PEPP program will be scrutinizing DRG coding,” said Cuerdon, “so make sure your coders know this coding system thoroughly.” According to Cuerdon, HIM staff members should probably review back issues of HCFA’s Coding Clinic and discuss difficult coding situations with their peers.
In addition, suggested Kam Valentine, director of communications and continuing medical education for CFMC, “Work very hard to make sure that all of your coders fully understand the finer points of coding, such as how to apply principal and secondary diagnoses, co-morbidities, complications, and principal and secondary procedures.”
Coding is not easy, Hammer noted. “It is a difficult process, and there are a lot of ‘gray areas,’” she said. “While this type of ‘refresher course’ may not seem necessary, it just might bring to light some common misunderstandings or misconceptions on the part of your coders.”
* Talk to your state’s PRO. Are you confused about the PEPP project? Do you have questions about it? Are you concerned about a possible coding error in your facility? “Call the PRO in your state,” Hammer urged. “We are really trying to stress that these types of calls are welcomed. The whole purpose of PEPP is to better educate HIM and other medical professionals about coding, billing and reimbursement processes.”
“Don’t try to hide your coding concerns from your PRO,” added HealthInsight’s Coss. “Instead, share them with the PRO. If something about the coding or reimbursement process strikes you as odd, call your state’s PRO and work on it together.”
* For a complete list of PROs and con-tact information for your state, visit ADVANCE’s Web site at www.advanceweb .com/hi.
