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AHIMA program focus: Documentation, coding

Corporate compliance plans address issues across the board, but details of health information management (HIM) compliance programs often are left for the staff to develop.

To help with this effort, the American Health Information Management Association (AHIMA) in Chicago recently introduced Health Information Management Compliance: A Model Program for Healthcare Organizations.

Elements may be there already

The program was written by Sue Prophet, RRA, CCS, AHIMA’s director of classification and coding, with guidance and input from the association’s eight-member fraud and abuse task force. The program was introduced at AHIMA’s 70th annual convention in New Orleans last October.

"[The program] expands on the concept of facilitywide compliance and focuses specifically on HIM issues related to documentation and coding," Prophet says. Many elements of an effective compliance program are already incorporated in policies and procedures but are not as detailed as explicitly as they need to be, she explains. "It creates some confusion on what you do in particular circumstances."

Prophet wrote the HIM compliance program to work across all settings, not just in acute care hospitals. "We tried to include other types of examples to show that a lot of the concepts and the points about complete documentation and coding and how to do auditing applies to whatever setting you are working in."

The plan is timely in that many hospitals are in the process of developing an HIM compliance program, she says. The document, however, should be used as a guide, not as a final plan. "This is not intended as a document that people could purchase and stick on a shelf and say, Now we have one.’ It is intended as a document that they can take and examine. It reminds them of all of the points and issues that they need to address and consider within their own HIM compliance program."

Since the document is intended as a guide, points in the document don’t give formal instructions. Instead, they might recommend that HIM staff "consider how they are going to answer the following questions when they develop their plan."

"It doesn’t necessarily have all of the answers because that depends on the culture and the way your organization is organized," Prophet says. "There is no right’ answer, but you have to remember to address that particular situation in your compliance program."

Prophet says she broke the program into nine elements, which are based on the key elements within the Office of Inspector General (OIG)’s Compliance Guidance for Hospitals. The Washington, DC-based OIG, released its guidelines in February 1998. These elements are:

o Mission statement.

An organization should have an HIM mission statement as well as a mission statement for the entire facility, Prophet says. For example, an HIM mission statement may begin, "HIM staff are committed to ethical and legal business practices, and committed to developing policies and procedures that are consistent with reimbursement regulations and official coding rules and guidelines."

o HIM code of conduct.

Every employee, including contracted consultants and independent contractors, should be asked to sign and date an HIM code of conduct, she says. "We recommend AHIMA’s Standards of Ethical Coding as the basis for one’s code of conduct regarding coding practices."

o Oversight.

Just as an organization has a corporate compliance officer, someone should be charged with the responsibility of oversight of the HIM compliance initiative, Prophet says.

The HIM compliance specialist should be responsible for monitoring the HIM compliance program and ensuring that staff are adhering to it. A separate position, however, does not have to be created for the oversight responsibility.

o Policy and procedures.

Comprehensive policies and procedures for coding, documentation, record retention, contractual arrangements, and outsourcing should be included, says Gloryanne Bryant, ART, CCS, with Tenet Health System in San Ramon, CA. Bryant spoke about HIM compliance programs at AHIMA’s convention.

o Training and education.

Required qualifications and experience for coding positions should be described, Bryant says. Ongoing education must be provided to coding personnel, independent contractors, and clinical personnel responsible for documenting in the medical record.

o Communication.

A procedure for communicating regulatory changes as well as a mechanism for reporting perceived compliance violations should be established, she says. Mechanisms should also be in place to communicate with physicians on coding and documentation issues and to obtain clarification regarding policies and procedures.

o Auditing and monitoring.

Organizations should conduct focused reviews on OIG target areas and structure a formalized audit process to review established baselines and process any identified variations, Bryant says. Coding accuracy should also be monitored regularly.

o Enforcement.

Violation of the organization’s standards of conduct, policies, and procedures, or federal or state laws should be addressed by appropriate and consistent disciplinary mechanisms, she says.

o Problem resolution and corrective action.

Any potential problems should be promptly investigated and appropriate corrective action should be initiated, if necessary, Bryant says.

Appendices offered, too

Also in the publication are appendices that HIM staff may find helpful, Prophet says. The appendices include "a list of HIM skills that are fundamental to effective compliance. We realize that some people who use this document might not be HIM professionals," she explains. "We tried to include information that explains what the HIM expertise is, how they can be involved, and why they are so important to the organizational compliance initiative."

The following are included:

- sample outlines for educational program topics — topics that could be included in internal educational programs for other departments, such as the admitting department, the business office, or the medical staff;

- a sample job description for the HIM compliance specialist;

- sample audit forms;

- sample communication tools for working with the medical staff;

- other AHIMA resources, such as practice briefs and information on coding competencies.

Editor’s note: Health Information Management Compliance: A Model Program for Healthcare Organizations by Sue Prophet, RRA, CCS, is $32 for AHIMA members, and $40 for nonmembers. This price does not include shipping and handling.

For more information, call AHIMA. Telephone: (312) 787-2672. World Wide Web: