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Practicing Coding Compliance
By Amy Wright, CPC-H, CCP-H, CPC, CCP, CMBS

I am often asked why an organization should develop a coding compliance plan. Such a plan provides guidance in the form of policies and procedures from the point of care to billing on claim forms, documentation of an agency’s intent to correctly report services, and the key to preventing coding errors that result in reduced reimbursement. The compliance plan should be a database of consistent, accurate, and reliable data assuring ethical coding practices and provide a reference in the event that coding practices are questioned.

The Office of Inspector General oversees coding and billing as the biggest compliance risks for healthcare. General education is required for all provider employees, but strong training is recommended for those in coding and billing. Education is the key when being compliant and training staff to maintain records by charge master review each year is critical.

The following policies should be included in a coding compliance plan:
• facility documentation;
• payer regulations and policies; and
• contractual agreements for coding consultants and other services.

Coding guidelines are developed by AHIMA, the American Hospital Association, the Centers for Medicare & Medicaid Services, the National Center for Health Statistics, and other quasi-official sources along with local and national coverage determinations. The national coverage determinations describe whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare in accordance with the Social Security Act. The local coverage determinations are developed to specify under what clinical circumstances a service is reasonable and necessary. ICD-9 codes support medical necessity, and the ICD-9 guidelines play a critical role in payment.

The question I find most coders asking is “Who is responsible for assigning these codes?” Ultimately, the physician is responsible. So when documentation is unclear, always query the physician. More and more, the coder’s position requires making sure what the physician documents is what he is coding. When establishing policies and procedures for auditing coding for accurate reporting, number the type of records to be audited, target proficiency rate, address severity of errors and provide education, and follow up on review and questions.

Make sure your coders have the essential resources since this plays an important role in their accuracy in coding and auditing. Resources such as ICD-9-CM coding books, CPT books, HCPCS, and 3M will not only help them perform at their best but also keep compliant with up-to-date materials as well. Be prepared to stand behind your coders and their coding decisions. Keep your coding compliance plan up-to-date and you will stay compliant.

— Amy Wright, CPC-H, CCP-H, CPC, CCP, CMBS, acts as a coder educator for CHI KentuckyOne Health and a coding compliance consultant with Kraft Healthcare Consulting, LLC, an affiliate of Kraft CPAs PLLC.