Guest Post: Creating an inpatient coding compliance plan

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

To limit exposure to claim denials and external reviews, the best safeguard for a facility is a robust, effective internal coding compliance policy, plan, and program.

Begin by reviewing any existing coding policies and procedures to determine whether they are consistent with the organization’s compliance plan, as well as the latest Official Guidelines for Coding and Reporting. If your department lacks compliance policies and procedures, excellent resources are available at JustCoding, ACDIS, AHIMA and the Hospital Corporation of America.

A facility’s coding compliance plan may be a subsection of the policy. If you format your compliance plan as a subsection, the document should be labeled “coding compliance policy and plan.” The plan component should be much more detailed and include the specifics of what, when, and how often. Each organization should tailor its coding compliance plan to its organization.

When developing a new coding compliance plan, managers should begin by asking these questions:

• Why am I establishing a plan?
• What will I review?
• How will I select a sample?
• How will I assess accuracy?
• What action will I take when the results are known?
• How will I monitor progress?

The coding manager should collaborate with the compliance officer in developing the plan. Some components that should be considered when you create your plan are:

Purpose: The purpose of the XYZ Hospital Compliance Plan is to improve the accuracy and integrity of patient data, ensure minimal variation in coding practices, serve as a conduit to improve provider documentation in the electronic patient record, and support XYZ Hospital’s ability to receive its entitled reimbursement for the services it and its providers provide.

Expectation: Staff (employees and, when applicable, contracted staff) will strive to maintain the highest level of professional and ethical standards in the performance of their coding duties. Staff will be trained and oriented in all applicable federal and state laws and regulations that apply to coding and documentation as relates to their positions.

Adherence to these guidelines is imperative. Where any questions or uncertainty regarding these requirements exists, it is the responsibility of the employee to seek guidance from a certified coding specialist, health information administrator, or another qualified coding professional. Staff will be familiar with prohibited and unethical conduct that relates to coding and billing as outlined in the facility compliance plan. Staff will comply with AHIMA’s Code of Ethics.

Education:

• All coders, billers, and providers will receive orientation and training in the fundamentals of compliant coding and billing. Continuing education will be provided in the form of handouts, memos, journals, in-services, and formal education as available and approved. To keep up with changes in regulatory requirements, coding changes, and proper coding procedures, it is the staff member’s responsibility to further his or her knowledge by reading all handouts, memos, and journals provided, and actively participating in available in-services and formal education workshops.
• All coders, billers, and providers will receive training in coding, documentation, and billing compliance issues on an annual basis or more frequently as need dictates. The training will be coordinated by the coding compliance subcommittee in conjunction with or in addition to training provided by the compliance office.

Coding resources: Coding staff shall have access to the following resources to facilitate their coding duties:

• Encoder
• Computer with dual monitors
• Coding books: ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures; other reference materials will be maintained in the coding manager’s office

Coding conventions and guidelines: The guidelines and conventions to be followed for codes to be reported on claims will be:

• Coding Clinic published by the American Hospital Association
• Official Guidelines for Coding and Reporting published by CMS and the National Center for Health Statistics

Editor’s note: This article was originally published in JustCoding. Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article is excerpted from JustCoding’s Practical Guide to Coding Management.