For best results in compliance and coding, here are some new guidelines

Use AHIMA’s standards of ethical coding

Health information management (HIM) systems, like hospitals, need to incorporate compliance program standards into their processes, ideally by following guidelines already established for hospitals by the American Health Information Management Association (AHIMA), according to an HIM expert.

"Our overall compliance message is consistency, continuity, and standardization, and to be able to achieve compliance in the coding arena we need those three components," says Gloryanne Bryant, RHIT, CCS, corporate director of coding/HIM compliance for Catholic Healthcare West in San Francisco. Bryant was set to speak at AHIMA’s 73rd National Convention and Exhibit on Oct. 13-18, in Miami Beach, FL, about Catholic Healthcare’s first-year experience with a coding/HIM compliance program.

"I’ve taken the key elements to health care compliance and applied them to the HIM coding arena," Bryant says. "At the corporate level, we have 48 acute care facilities and no prior standardized and centralized coding and HIM compliance direction."

Here’s how the HIM compliance program is established:

1. Identify mission and objectives.

"We demonstrate in our mission statement the commitment HIM professionals have," Bryant says.

A coding/HIM compliance program mission statement should:

  • be consistent with an organization’s mission statement;
  • address commitment to ethical/legal practices;
  • state a commitment to ethical/legal practices;
  • promote integrity, accuracy, consistency, reliability, and validity;
  • require HIM professionals to be committed to the development of internal policies and procedures;
  • promote HIM professional behavior;
  • ensure high-quality health information and accurate claims submission;
  • provide respect of patient and health information confidentiality.

For example, an HIM-compliance mission statement could read: "Coding/HIM Compliance Program strives to improve coding accuracy and the operations that affect clinical coded data in an effort to comply with federal, state, and regulatory statutes. Through the efforts of establishing policies and procedures, auditing and monitoring, education, communication, making recommendations, and developing actions, we will produce reliable data and clinical information that can serve to enhance positive health care outcomes for the patients we serve."

2. Establish a code of conduct.

Catholic Healthcare West used AHIMA’s standards for ethical coding as a guide for its own code of conduct, Bryant says.

"It’s available for employees to sign and acknowledge that they will abide by the code of conduct," she says. "Each year they sign it, and new employees sign it when they are hired."

Consultants, independent contractors, and other outsourced staff also sign the code of conduct. The forms are kept in personnel files.

3. Provide oversight for the company’s coding and compliance.

Bryant’s job is to provide oversight for the company’s coding and compliance. She reports to the company’s corporate compliance officer.

She recommends that the person overseeing coding and compliance be someone who is also a member and leader of the compliance committee/task force. The role of compliance responsibility should be given a high priority, and the person chosen for the job should be someone with a strong coding background who demonstrates honesty and integrity.

It’s important to place one person in charge of coding and compliance for an entire health care organization instead of having separate people for each facility, Bryant notes.

"As a health care system, in the past we were divided into regional areas, and some regions had one or two facilities or hospitals," Bryant explains. "They set up policies and procedures that were inconsistent with one another."

However, because the federal government treats a health care system as though it is one entity, the system needs to have consistency across all sites and must demonstrate this to the government, Bryant adds.

Comprehensive policies needed

4. Develop written coding HIM compliance policies and procedures.

The key is to develop comprehensive policies and procedures for coding, documentation, retention, contractual arrangements, and outsourcing, Bryant says.

The policies and procedures should address risk assessment areas and include clear, well-written internal coding practices.

"The first policy we developed was a foundational policy that has 22 bulleted items in it," Bryant says. "The first item is our code of conduct and standards of ethical coding, and the second is acknowledging that all staff and coding employees, including contract employees, shall adhere to our policy."

Other aspects of the policies and procedures include:

  • Create and provide official coding guidelines.
  • Make coding resources available.
  • Require continuing education. Catholic Healthcare West requires each employee to get 12 hours of continuing education in coding annually and to demonstrate this by maintaining certificates of attendance within the HIM department, Bryant says. "The logic behind this is because there are regulatory changes, sometimes on a monthly basis, we have to make sure our staff are keeping up with those requirements. This is one way to ensure we are staying abreast with the current coding issues and regulatory issues," Bryant adds.
  • Designate official sources for coding advice. "We talk about book references everybody needs to code well, and we list nine bulleted things made mandatory, including an ICD-9 book and a current CPT book," Bryant says.
  • Analyze accuracy rates for all settings.
  • When problems are identified, determine the causes and appropriate corrective actions.
  • Provide coding accuracy standards.
  • Ensure that documentation is available for physicians and other clinicians and that medical record documentation supports the claim. For example, one Catholic Healthcare West policy provides that coders will not code from lab values or lab symbols such as up or down arrows unless the physician quantifies these in the narrative description, Bryant explains. Instead, coders determine if there was clinical evidence of a condition by looking in the chart. They will ask the physician for a clarification if necessary.
  • Check comorbid and complication sample cases.
  • Incorporate payment policies and coding assignment into coding policies and procedures.
  • Provide payer coding advice and bulletins, encoder customized edits, and payer policy.
  • Institute specific arrangements with consultants, including how qualifications are evaluated and how internal monitoring is accomplished.
  • Retain records listing types of documents and how storage, retrieval, and destruction are accomplished.
  • Make compliance an element of performance review.

Newsletters, seminars provide education

5. Train and educate staff about HIM compliance.

The hospital system sponsors two free workshop seminars each year for its staff to update coders on coding changes. "We prepare and research all the material, and they can attend the whole day at no cost," Bryant says.

HIM staff may use these workshops to satisfy their continuing education requirements.

"All our education has objectives, goals, curriculum, and content that is available for review and for continuing education credits," Bryant says.

Because the hospital system is located in three states, there are six locations for the seminars, as well as opportunities for video teleconferencing for those who work in rural settings.

Another way staff are educated and kept up to date is through a coding compliance newsletter published several times a year.

"We get questions to research and share them back with the staff," Bryant explains.

Other education includes presentations to physicians and ancillary staff, inservices with case management staff and nursing staff, and education for management and hospital administration.

The final piece of education involves a new line coding and education coding web-based program purchased from MC Strategies of Atlanta. This involves taking on-line medical terminology courses in beginning, intermediate, and advanced CPT and ICD-9 coding. HIM staff can take these courses at any time that is convenient for them, but the policy requires them to go on-line to use the system for at least one hour a month, Bryant says.

"We want to make sure this tool is utilized, and we monitor and track and produce reports on who used the system and what their score was," she adds.

6. Keep communication open and fluid.

Communication is an important part of compliance, Bryant says.

All HIM/coding staff may contact Bryant directly, and any new information is sent to the health system’s HIM directors and coding supervisors through e-mail, regular mail, and video conferencing of meetings and presentations.

Coding questions answered in 24 hours

"We also have a coding-question fax form, which is a fact sheet," Bryant says. When a coding question arises, the question is described, researched, and answered via the fax form within 24 hours. This way, everyone sees the same question and answer.

7. Make provisions for auditing and monitoring of the program.

The health system has a full auditing program in which Bryant and other managers visit hospital facilities twice a year, doing inpatient coding validation and audits of outpatient surgery, emergency room coding, and ancillary coding, Bryant says.

Auditors validate ICD-9 and CPT codes and incorporate an HIM operational assessment that examines whether transcription reports are behind or other situations that might affect operations of an HIM department.

Other auditing features include:

  • Identifying areas of potential risk.
  • Evaluating internal coding practices. For example, Bryant wants staff to reroute coding paperwork when there has been coding without a discharge summary. "We have experienced resistance to this because it takes time," she says. "So when the discharge summary is here four weeks later, let’s look at it to make sure we captured everything we could."
  • Reviewing coding and DRG frequency on monthly, quarterly, and annual bases.
  • Comparing to national, state, and regional norms.
  • Monitoring coding accuracy.
  • Reviewing prospectively and retrospectively.
  • Reporting any violations found.
  • Resubmitting for both overpayment and underpayment. "We want to give back overpayments, but when we have money left on the table because we have not captured all of the codes, we should then want to rebuild and capture those dollars," Bryant says.
  • Documenting audit and monitoring activities, corrective action, and follow-up.
  • Auditing compliance program for effectiveness.

"In site visits, auditors use an auditing worksheet and standardized reporting, developing an actual response and action grid for the hospital and HIM director to use to see what they’re doing to respond to that," Bryant says.

In addition, Catholic Healthcare West uses the Systematic Monitoring And Review Technique (SMART), a coding compliance software application from PricewaterhouseCoopers, which has scan-coded information. "It helps us to clean things up before we bill," Bryant says.

8. Set corrective actions and enforcement.

A grid that is a communication tool is in place, serving to identify those areas that need corrective action based on the results of an audit.

"We’ve been trying to track compliance better to see where we need stronger enforcement and to see whether people are adhering to our policies," Bryant says.

Accountability on all levels is needed to make compliance work, she adds. "Upper management also need to know what’s going on and be accountable," she says.

Corrective actions may include:

  • mechanisms for appropriate discipline;
  • multidisciplinary involvement;
  • responding to problems and initiating corrective actions;
  • recording investigation process;
  • informing all employees about corrective action.