TABLE OF CONTENTS

SECTION 1: CODING COMPLIANCE PROGRAM

  • Coding Compliance ProgramI.I

SECTION 2: EMPLOYEE EDUCATION

  • Generic Training for All Coding StaffII.I
  • Specialized Training Regarding Coding ComplianceII.I
  • MethodsII.2
  • Identification of Responsibilities of Each Job ClassII.3
  • Persons responsible for Assuring that Each Job Class receives

Appropriate TrainingII.3

SECTION 3: COMPLIANCE OFFICER

  • Coding Compliance OfficerIII.1

SECTION 4: ESTABLISHED STANDARDS

  • Minimum Documentation RequirementsIV.1
  • The Uniform Hospital Data Discharge SetIV.1
  • Coding QualityIV.1
  • Coding Guidelines
  • Essentials of Accurate Coding
  • Sequencing of Principal Diagnosis and Procedure
  • Assignment of DRG and ASC
  • Use of Encoder
  • Outsourcing of CodingIV.1

POLICIES AND PROCEDURES MANUAL FOR CODING COMPLIANCE

SUBJECT: EMPLOYEE EDUCATIONS

MANUAL: MODEL COMPLIANCE

Standard:All coders are required to pass a skill competency test prior to employment. Upon employment and yearly thereafter, all coding staff shall complete the training components as outline below:

1.Generic Training for All coding Staff:

A.Ethics Training

1.Examples of coding Compliance Program as part of ethical responsibility and as it relates to all employee responsibilities.

B.Review of related policies and procedures

1.AD/C/1: Ethics and Professional Conduct

2.HR/B/8:Employee Conduct

3.HR/A/4:Counseling Action System

2.Specialized Training Regarding Coding Compliance:

Groups to receive specialized training and level of specialized training to be received:

1.Laboratory Services: Level 1

2.Business Office: Level 1 and 2

3.Health Information Management: Level 1 and 2

a. Inpatient

b. Outpatient

c. Ambulatory

d. ECU

e. Outpatient Dx

4.Ancillary Departments: Level 1

5.Industrial Medical Center: Level 1 and 2

6. ?? Level 1 and 2

7. ?? Level 1 and 2

8.LPCP: Level 1 and 2

9.TAU: Level 1 and 2

10.Southern Regional: Level 1 and 2

11.Other

a. IOS: level 1 and 2

  1. Behavioral/Mental Health-Family Managed Care: Level

1 and 2

c. St. Anthonys: Level 1

d. Other Employed Physician Staff: Level 1 and 2

e. N.H.: Level 1 and 2

f. Contracted Services: Level 1 and 2

g. Home Health

3.Methods:

A.Specialized Training

1.Level 1

a. CPT-4

b. HCPCS

c. Medical Terminology

d. Anatomy and Physiology

e. Basic Disease

f. Documentation

g. Confidentiality

h. Review of Department Specific Policies

2.Level 2

a. ICD-9-CM

b. CPT-4 Advanced

c. Government and Insurance Regulations

d. Glossary of Terms

e. Oversight Agencies

4.Identification of Responsibilities of Each Job Class:

A.Generic statements in house-wide job descriptions

  1. Specific identification of responsibilities of relevant job classes

(e.g. Lab, Billing, HIM, LPCP, etc).

C.Identification of competency required for each job class

5.Persons responsible for assuring that each job class receives appropriate training:

A.Coding Center Trainer

- Develop training classes

- Provide updates and in-services on new laws or regulations

- Implement quality audits

- Compare diagnosis cods with procedure codes

- Document physician clarifications.

B.Coding Quality Analyst

C.Coding Assistance Line

- Provide immediate assistance for day-to-day coding issues

POLICIES AND PROCEDURES MANUAL CODING COMPLIANCE

SUBJECT: COMPLIANCE OFFICER

MANUAL: MODEL COMPLIANCE

Coding Compliance Officer (CCO):

The Coding Compliance Officer is the Director of the Healthy Information management Department. This person is responsible for developing the compliance policies and standards, overseeing and monitoring the compliance activities, and achieving and maintaining compliance. Responsibilities and duties for the CCO will include:

  1. Assure that up-to-date, comprehensive internal policies and

procedures for coding and billing are developed and maintained.

  1. Responsible for assuring consistent coding practices throughout

hospital departments.

  1. Responsible for ensuring appropriate ongoing education for all

coding employees including coding compliance issues and ethics

training.

  1. Responsible for regularly updating education for all coding

employees as standards change.

  1. Responsible for monitoring the documentation supporting the

medical necessity of services provided by the facility.

  1. Assure that all coding personnel are informed of issues pertaining

to Medicare medical necessity guidelines.

G.Responsible for monitoring that the facility maintains signed Physician Acknowledgement Forms.

H.Thoroughly analyze coding consultants' recommendations before implementing them.

I.Periodically compare facilities' DRG distribution with national data, and physicians' evaluation and management code usage with others in the same specialty and region.

J.Participate in the evaluation of claims denials as presented at the Reimbursement Committee Meeting.

K.Periodically examine organizational data over the past several years to determine inconsistencies.

L.Ensure that all records required either by Federal or State law or by the compliance plan are created and maintained.

M.Assure that evaluations of managers and supervisors include a component requiring the promotion and adherence to compliance.

N.Responsible for notifying the Corporate Compliance Officer of suspected violations of law or misconduct regarding billing.

O.Maintain the confidentiality of any person reporting potential areas of concern and assure that no recriminating acts shell be taken.

  1. Responsible for initialing corrective action to improve compliance

processes

  1. Establish minimum competency education requirements for all

coders.

POLICIES AND PROCEDURES MANUAL FOR CODING COMPLIANCE

SUBJECT: ESTABLISHED STANDARDS

MANUAL: MODEL COMPLIANCE

The program should ensure appropriate documentation, coding and billing practices. This includes cost reporting, UB-92 billing of inpatient services and appropriately assigned chargemaster lines.

1.Standards for Documentation and Coding

A.Minimum Documentation Requirements (Attached)

B.The Uniform Hospital Data Discharge Set (UHDDS)

C.Coding Quality

1.Coding Guidelines (See Appendix 1)

2.Essentials of Accurate Coding (See Appendix 2)

  1. Sequencing of Principal Diagnosis and Procedure (See

Appendix 3)

4.Assignment of DRG and ASC

  1. Use of ICL-9-CM and CPT code books, computerized

coding systems (encoders) which follow coding

guidelines and are updated yearly with HCFA (Health

Care finance Administration) Yearly prospective

payment system changes.

  1. Knowledge of medical record procedures,

terminology, anatomy and physiology and medical

science.

D.Outsourcing of Coding

1.Contract clause to include coding compliance.

2.DRG/CPT Coding Review.

3.All contract coders will follow coding compliance guidelines and meet coding education requirements.

POLICIES AND PROCEDURES MANUAL FOR CODING COMPLIANCE

SUBJECT: PROGRAM AUDITS

MANUALS MODEL COMPLIANCE

1.Periodic Audits

Audits should be conducted to ensure the accuracy of clinical documentation, coding and DRG assignments. Audits should be scientifically designed to provide reliable assessment of current coding practice and should encompass both inpatient and outpatient services. The quality Coding Analyst shall be responsible for designing and conducting these audits. All cases in which coding revisions result in lower or higher weighted DRG assignment shall be identified, correctly billed and written documentation of those cases will be maintained.

2.Data Monitors

Data Monitors shall be implemented to track key indicators of patient mix and coding practices. Such indicators may include case mix index, complication rates and reporting or potentially problematic diagnoses and procedures. Identification of abnormalities or variations should trigger the need for a comprehensive audit. The Quality Coding Analyst in conjunction with the Decision Support Department shall develop monitors and reporting mechanisms to appraise all coding entities.

3.Process Controls

Process controls shall be Instituted to establish responsibility and accountability among departments. Quality controls and feedback mechanisms shall be developed to help identify any problems and correct it on a timely basis.

4.Internal Audits

The Internal Audit Department of will perform regular, periodic compliance audits of the "coding processes". These audits will be designated to monitor compliance with the coding compliance policies, compliance plan, and all applicable Federal and State laws.

Compliance audits will be conducted in accordance with the following pre-established audit procedures:

A.Review the Coding Model Compliance Plan's written policies and procedures for completeness. Verify the following issues are adequately addressed:

1.Standards of conduct for all employees

2.Coding practices.

3.Coding Fraud Alerts from regulatory agencies.

4.Record retention.

5.Educating and training personnel regarding compliance.

6.Coding Compliance Officer responsibilities.

7.Disciplinary action with respect to compliance adherence.

8.Corrective action.

9.Performance evaluation with respect to compliance.

10.Minimum coding education requirements for any one doing coding.

11.Method established for documenting continuing eduction.

B.Interview Coding personnel regarding coding policy and procedures. Determine:

1.How they make a code selection.

2.Their understanding of accurate coding vs "up coding"

3.Who do they call for coding assistance.

4.Who reviews their coding work.

5.Does the Supervisor review Coding Fraud Alerts from regulatory agencies and inform other coding personnel if appropriate.

C.Select a sample of employees who have coding responsibilities and obtain their Human Resources records. Review the records for the following:

1.Level of coding education.

2.Level of current continuing education on coding.

3.Verify form signed by employee stating they understand the organizations coding policies and procedures.

4.Verify job description and evaluation includes that employees are accountable for the quality of their work.

5.If appropriate, action taken for suspected inappropriate coding practices.

D.Review a sample of coded material and verify that:

1.Coding is standardized throughout the organization.

2.Codes are supported by medical necessity and the appropriate documentation is present to support a code.

3.All procedures, test, and services have an appropriate order.

4.The code applied is the most appropriate code.

5.Billing has occurred for appropriately coded material and no billing has occurred for inappropriately coded material.

6.Corrective action has been taken and documented when inappropriate coding has occurred.

7.Review plan for ongoing monitoring of the coding process.

E.Obtain a copy of the HIM's and any other entity that bills for hospital employees' current organizational chart, select a sample of Manager’s and Supervisor's positions, and perform the following:

1.Obtain a copy of the job description for each position s elected.

2.Verify that the promotion of and adherence to compliance is an element in evaluating the performance of Mangers and Supervisors.

F.Obtain HIM's education and training schedule for the current year, obtain a list of all employees with coding responsibilities, select a sample, and perform the following:

1.Trace to written documentation that the employee has attended compliance education and training.

2.Review Compliance training material and verify that the material:

a.Emphasizes the organization commitment to comply with all laws, regulations and guidelines of Federal and State programs.

b.Covers the coding compliance policies.

c.Reinforces the fact that strict compliance with the law and coding policies is a condition of employment.

d.Informs employees that failure to comply with the law and the Coding policies may result in disciplinary action, including termination.

e.Informs employees that appropriate disciplinary action up to and including termination for failure to report a potential violation by another employee, supervisor or outside contractor or provider.

G.Review coding fraud alerts for the current year. Verify that the facility has reviewed its practice covering the referenced items, taken appropriate action if needed and made employees aware of any potential problems.

H.Based on Federal and State law and the compliance policies and procedures, select a sample or records and verify that the records are created and maintained in accordance with Federal and State law and by the compliance policies and procedures.

A written audit report will be issued at the end of each compliance audit, which will be submitted to the Corporate Compliance Committee of ______. The audit reports

will identify areas where corrective actions may be needed. Internal Audit will perform follow-up audits to monitor that corrective actions stipulated by the committee have been implemented and are functioning as intended.

APPENDIX I

CODING GUIDELINES

1.Follow all coding principles outline in the "Essentials of Accurate Coding," (See Appendix 2).

1.1Use all codes necessary to completely code all diseases and procedures, including underlying diseases.

1.2Refer all medical records of patients treated for multiple trauma and patients hospitalized over thirty days to the coding supervisor to verify selection of principal diagnosis before abstracting.

1.3M codes are not used.

1.4E codes are used whenever appropriate to identify external codes.

1.5J,Q,A and W codes are required for Outpatient Services.

2.Consult the following sources to identify all diagnoses and procedures requiring coding and to increase the accuracy and specificity of coding.

2.1Face Sheet-code diagnoses and complications appearing on the face sheet.

2.2Progress Notes-Scan to detect complications and/or secondary diagnoses for which the patient was treated and/or procedures performed.

2.3History and Physical-scan to identify any additional conditions; such as history of cancer or a pacemaker in situ. These conditions should be coded.

2.4Discharge Summary-read if available and compare listed diagnoses with face sheet. Code diagnoses and procedures listed on discharge summary but not specified on face sheet.

2.5Consultation -scan to detect additional diagnoses or complications for which the patient was treated.

2.6Operative Reports-scan to identify additional procedures requiring coding.

2.7Pathology Reports-review to confirm or obtain more detail.

2.7.1Obtain pathology report from current admission or request findings by phone to code neoplasm.

2.7.2.If pathology report disagrees with face sheet, use pathology report to code and advise physician of the discrepancy on the deficiency report.

2.7.3Consult previous medical records in patients admitted for follow-up of neoplasms to determine the primary and secondary sites.

2.8X-ray and laboratory-use reports as guides to identify diagnoses (e.g. types of infections) or more detail (e.g. type of fractures).

2.9Physician's Orders-scan to detect treatment for unlisted diagnoses-the administration of insulin, antibiotics, sulfonamides may indicate treatment of diabetes, respiratory or urinary infections which should be confirmed by checking other medical record forms.

3.Code incomplete face sheets by reviewing the above items.

3.1Record codes assigned in pencil on the fact sheet.

3.2Request supervisor's assistance if difficulty is encountered in identifying codable data by scanning record.

3.3Call physician for diagnostic information only if instructed to do so by supervisor.

4.Exercise discretion in coding diagnostic conditions not identified on the face sheet or discharge summary.

4.1Query physician on the deficiency report if the coding question influences DRG assignment.

4.2Review all alcohol/drug abuse cases to confirm prior to coding.

5.Process special diagnostic coding situations as follows:

5.1V codes are used to identify encounters for reasons other than illness or injury. V codes are used as principal diagnoses for newborn admissions (V30.0-V37.0), Chemotherapy session (V58.0), Radiotherapy session (V58.1), Removal of fixation devices (V54.0), and Attention to Artificial openings (V55). For inpatient coding, avoid the use of V codes as the principal diagnosis where a diagnosis of a condition can be made.

5.2V codes are used in outpatient coding when a person who is not currently ill obtains health services for a specific purpose, such as, to act as a donor, or when a circumstance influences the persons health status but is not in itself a current illness or injury. Patients receiving preoperative evaluations receive a code from category V72.8.

5.3Avoid using codes that lack specificity. These vague codes should not be used if it is possible to obtain the information required to assign a more specific code.

5.4Inpatient coding requires that signs and symptoms are coded when a specific diagnosis cannot be made or when the etiology of a sign or symptom is unknown. Do not code symptoms if the etiology is known and the symptom is usually present with a specific disease process. Example: Do not code convulsions with the diagnosis of epilepsy.

5.5Outpatient coding requires that diagnoses documented as "probable, suspected, questionable, rule out or working", should not be coded. Code the condition for that visit, i.e., signs or symptoms or abnormal test results.

5.6Chronic conditions may be coded as many times as the patient receives treatment.

5.7Code abnormal laboratory tests only when noted on the face sheet by the attending physician.

5.8When there are more than nine diagnoses for a hospitalization, acute conditions take precedence over chronic and at least one comorbid condition or complication should be included in the nine diagnoses that may be submitted to Medicare. All complications and comorbitities should be reported for calculating severity of illness.

6.Sequence diagnoses and procedures according to the "Guidelines for Sequencing and Designating Principal Diagnosis and Principal Procedure Codes." (Appendix 3).

7.Code all procedures performed in the hospital from the time of admission to the time of discharge.

7.1Be certain procedures were actually performed, not just ordered or consents obtained.

7.2Code procedures clearly documented in the record but not indicated on the face sheet or in the discharge summary. Note codes for such procedures in pencil on the face sheet.

7.3Code all Class I procedures except fetal monitors.

7.4Code all Class II procedures except shock therapies and cardioversions.

7.5Code Chemotherapy and Radiation Therapy (Class IIIs) and no other Class IIIs.

7.6Code only Class IV procedures used in DRG assignment.

7.7If only two diagnostic procedures are performed and both relate to the principal diagnosis, sequence the procedure in the higher class as the principal procedure.

7.8If two or more treatment procedures or two or more diagnostic procedures

APPENDIX 2

ESSENTIALS OF ACCURATE CODING

1.Identify all main terms or procedures included in the diagnostic/procedural statements(s).

2.Locate each main term/procedure in the Alphabetical Index. A main term may be followed by a series of terms in parentheses. The presence or absence of these parenthetical terms in the diagnosis has no effect upon the selection of the code listed for the main term.

3.Refer to any subterms indented under the main term. These subterms for individual line entries and describe essential differences by site, etiology or clinical type.