DRG Coding Advisor: AHIMA recommends coding policy change to Congress

Goal is guideline consistency

The American Health Information Management Association (AHIMA) of Chicago recently presented its concerns, observations, and suggestions about medical coding systems to the National Committee on Vital and Health Statistics Standards and Security subcommittee. Sue Prophet, director of coding policy and compliance for AHIMA, outlined the following recommendations during her recent testimony:

• All payers and providers should be required to adhere to the existing code-set rules, definitions, and guidelines as developed by the code-set maintenance organization and published as part of the code set. HIPAA (Health Insurance Portability and Accountability Act) regulations should be modified to require that users or covered entities follow a code set’s rules, definitions, and guidelines in line with our other recommendations.

• Coding guidelines should be part of the standard code set so that all users must abide by them. HIPAA regulations should be modified to reflect this requirement. The coding system rules and guidelines should be updated on the same schedule as the code set.

• Every accepted standard medical data code-set organization must be required to have an organized process for the development and maintenance of the codes and rules and guidelines for the correct, consistent use of their code set. The process for developing codes, code-set rules, and guidelines for proper use of the medical code sets should include broad access and input and approval representation from a range of stakeholders, including coding and clinical experts, practitioners, and users. Input should be solicited prior to finalization of a new or significantly revised rule or guideline and meetings should be open to the public or at a minimum to the stakeholders. Notice of meetings should be posted at an appropriate time in at least the Federal Register, and the agenda and information on submitting items for the agenda should be posted in a suitable manner.

• All these processes should be placed under the supervision or oversight of a single entity or authority. Such an entity should provide oversight and authority to the guideline development process for each medical code set, ensure consistency in processes, and ensure that the various standard code sets complement one another and work in tandem without duplication or overlap. To this degree, such an authority would act much as the American National Standards Institute does with its various standards groups. Such centralization exists in most other countries.

AHIMA also made the following recommendations for improvement of medical coding:

  • A single procedural coding system should be developed and adopted for use across all sites of health care services.
  • There should be a federally funded examination on the feasibility of moving to a single system that examines:

— The efficacy of alternative systems across all health care settings, for all payer types, and all types of health care services. It should also address the need for uniform data to fulfill the needs of a national health care and public health infrastructure, health care research, other non-treatment use of health care data.

— The implementation and long-term cost and benefits of a single system compared to that of operating multiple systems.

— A recommended strategy for implementation that takes into account the need to implement ICD-10-CM.

• The Healthcare Common Procedure Coding System (HCPCS) should be revised to recognize the single procedural coding system as the only coding system to be used for procedures and services. HCPCS should then become a coding system, with a more open development and maintenance process, representing only the products, technology, and supplies that are not procedures and services.