Drug Coding Advisor-How coding reviews could save you $30 million

Good reviews are worth bundles

Is precise coding really that important? If you're still asking that question, even just occasionally to yourself, consider this: "The University of Pennsylvania is now in the process of paying $30 million to settle an action that grew out of a government review of just 100 of its medical records," notes Lynne Northcutt-Greager, a coding expert with the Medical Group Management Association (MGMA ) in Englewood, CO.

Add to that the fact that quality coding helps minimize delayed or incorrect reimbursement and reduces denials based on lack of documented medical necessity, which improves fast flow.

"The best mechanism for improving your coding performance is a coding review," stresses Northcutt-Greager. Regular coding reviews need to be a basic part of your compliance program. Whether or not you're already doing scheduled reviews, here are some suggestions from Northcutt-Greager and MGMA on how to structure a coding review for maximum effectiveness:

Goal setting. What are the goals of the review? Should it be prospective or retrospective? What types of services should be looked at? Which payers will you focus on? Are there multiple locations that need to be reviewed?

Choosing a reviewer. The criteria for selecting a coding reviewer depends on the areas on which your organization needs to focus. Different reviewers will approach the review from different perspectives, depending on whether their backgrounds are in accounting or insurance, for example. Consider the reviewer's qualifications, expertise, education, and training. Make sure the reviewer knows your specialty and the issues on which you want to focus.

Scope. Once the reviewer has been chosen, you need to decide on the scope of the review. The reviewer and administrator should work together to decide whether the reviewer will: examine physician production; review forms used in the organization; compare medical record documentation to actual services provided; compare payer billing requirements to specific patient records; and review operational areas like billing processes and information flow.

"There's no standard reviewing format that covers all the bases for every practice," notes Northcutt-Greager. Reviews will vary depending on the organization's size, specialty, and payer contract requirements. That's why it is important that the reviewer gears the review to the issues affecting your organization.

Post-review. After the review, you'll have to start thinking about how to implement the reviewer's recommendations. Be prepared; this could involve further evaluation, training sessions, software upgrades, corrected billings or refunds, or even consultation with legal counsel, she advises.

Basically, "you'll need to respond to anything that's a potential compliance problem."

Here are some other recommendations from the MGMA for immediately upgrading your coding:

• Make sure current copies of coding books and reference materials are available to everyone involved in the coding process.

• Send staff to seminars on coding.

• Hold periodic staff meetings to discuss coding issues.

• Communicate updates and make Medicare and other payer bulletins available.

• Make sure everyone responsible for accurate coding understands the material.