PAGE: 1 of 8 / REPLACES POLICY DATED:
APPROVED: September 2, 1998 / RETIRED:
EFFECTIVE DATE: September 2, 1998 / REFERENCE NUMBER: HIM.COD.010
SCOPE:
All Company facilities including, but not limited to, hospitals and all Corporate departments, groups and divisions.
Employees responsible for performing, supervising or monitoring coding/claims processing of inpatient and outpatient services, including, but not limited to, employees in the following departments:
Health Information ManagementConsulting & Audit Services
Health Information Management ServicesAdministration
Business OfficePhysician Advisors
Case Management/Quality Resource ManagementExternal Coding Contractors
Ethics and Compliance OfficerSNU Director
MDS Coordinator
Applies to diagnosis and procedure coding of all skilled nursing services provided in Columbia facilities. For outpatient services, refer to the Coding and Documentation Policy for Outpatient Services (Reference Number HIM.COD.002).
PURPOSE:
To improve the accuracy, integrity and quality of patient data, ensure minimal variation in coding practices, and improve the quality of the physician documentation within the body of the medical record to support code assignments. The Company’s commitment to data integrity is documented on Attachment A.
POLICY:
Diagnoses and procedures will be coded utilizing the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and/or other classification systems that may be required (such as DSM IV for classification of psychiatric patients). The Company will follow the Official Guidelines for Coding and Reporting diagnoses and procedures published in AHA Coding Clinic for ICD-9-CM, Second Quarter, 1990 and Fourth Quarter, 1996 or the most current AHA Coding Clinic Guidelines.
PROCEDURE:
1.ICD-9-CM/AHA Coding Clinic
Diagnoses and procedures will be coded utilizing the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and/or other classification systems that may be required (such as DSM IV for classification of psychiatric patients).
The Company will follow the Official Guidelines for Coding and Reporting diagnoses and procedures published in AHA Coding Clinic for ICD-9-CM, Second Quarter, 1990 and Fourth Quarter, 1996 or the most current AHA Coding Clinic Guidelines.
2.UHDDS Definitions
Skilled nursing diagnoses and procedures shall be coded in accordance with Uniform Hospital Discharge Data Set (UHDDS) definitions for principal and additional diagnoses and procedures as specified in the Official Guidelines for Coding and Reporting.
a)The principal diagnosis is defined as follows:
i1The admitting diagnosis is defined as the condition for which the patient was admitted to the SNF, to receive skilled nursing services, and should be one of the conditions for which the patient received hospital care in the qualifying hospital stay. Reference: Medicare Manual, Section 560, Completion of HCFA-1450 (UB-92), definition of principal diagnosis.
ii1The UB-92 definition for principal diagnosis cannot always be applied in every circumstance. The Company recognizes that unique payer coding and billing requirements exist. The procedure for addressing unique Payer requirements is addressed in Section 8 of this policy.
iii1The use of V codes as principal diagnosis may be appropriate in some circumstances (Coding Clinic 4th quarter, 1996). Unique payer requirements must be taken into consideration when using V codes as principal diagnosis.
c1The UHDDS defines additional diagnoses as, “all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay.” Diagnoses that relate to an earlier episode which have no bearing on the current Skilled Nursing Unit/Facility stay are to be excluded.
3.Reportable Diagnoses/Procedures
To achieve consistency in the coding of diagnoses and procedures, coders must:
a)Thoroughly review the entire medical record as part of the coding process in order to assign and report the most appropriate codes;
b)Adhere to all official coding guidelines as stated in this policy;
c)Assign and report codes, without physician consultation/query, for diagnoses that are not listed in the physician’s final diagnostic statement only if those diagnoses are specifically documented in the body of the medical record by a physician directly participating in the care of the patient, and this documentation is clear and consistent;
i)Areas of the medical record which contain acceptable physician documentation to support code assignment include the discharge summary, history and physical, physician progress notes, physician orders, and physician consultations.
ii)When diagnoses or procedures are stated in other medical record documentation (nurses notes, MDS abstracts (SNUs), pathology reports, radiology reports, laboratory reports, EKGs, nutritional evaluations and other ancillary reports), the attending physician must be queried for confirmation of the condition. These conditions must also meet the coding and reporting guidelines outlined in AHA Coding Clinic, 2Q, 1990 page 12.
d)Utilize medical record documentation to provide specificity in coding, such as utilizing the radiology report to confirm the fracture site or referring to the EKG to identify the location of an MI.
4.Query Process
Query the physician once a diagnosis or procedure has been determined to meet the guidelines for reporting but has not been clearly or completely stated within the medical record by a physician participating in the care of the patient or when ambiguous or conflicting documentation is present.
a)The documentation of the coder’s query to the physician must comply with one of the following formats:
i)The physician can add an addendum to the medical record. The addendum must be dated and signed.
ii)The query can be documented on a separate query form.
a)This documentation must be kept as a permanent part of the medical record and must include the patient’s name, the patient’s medical record number, the name of the individual submitting the query, the date the query was submitted, a statement of the issue in the form of a question, and the physician’s response to the query. It must be signed and dated by the physician.
b)If the query process is documented in this format, a second signature is not required on the coding summary.
iii)The query process can be documented on the coding summary.
a)This documentation must be kept as a permanent part of the medical record and must include the name of the individual submitting the query, the date the query was submitted, a statement of the issue in the form of a question, and the physician’s response to the query. The query must be signed and dated by the physician.
b)A statement indicating physician agreement with the diagnoses and procedures reported must be included as part of the coding summary.
(1)A notation that this form will be included as a permanent part of the medical record should also be included.
(2)The following statement has been approved for use by the Columbia Coding Classification Steering Committee:
I have reviewed the narrative descriptions of the diagnosis and procedure codes listed above and agree they accurately reflect the clinical picture of this episode of care.
(a)An NPR report has been developed for use on the Columbia Patient Care System (CPCS). This format will be downloaded to the network for CPCS versions 4.4 and 4.5 (separate notification will be provided when this NPR report is available.) Version 4.6 will allow language changes without a NPR report. CPCS sites will be required to use this language when the NPR report is available unless payer requirements exist. Until the NPR report or 4.6 is available, continue use of the attestation statement language.
(b)For non-CPCS facilities that have the ability to change the physician agreement language, the above statement should be used. If your facility is using the previous attestation statement based on inability to change the language or payer requirements, this statement will also be acceptable.
c)The query process can be documented on a concurrent or retrospective basis.
d)It is not necessary to maintain the concurrent query for diagnoses or procedures which the physician includes in the body of the medical record. If, however, the physician does not update the medical record documentation, this query must be maintained as a permanent part of the medical record to support code assignments.
e)The retention of the query documentation is related to codes reported at the time of final billing.
f)It is necessary to include a chart that requires a physician response to a coding query in the incomplete and delinquent record count.
g)It is required that the Health Information Management Director ensure that the query form has been officially approved by the medical staff to be included as a permanent part of the medical record.
i)Preprinted query forms should include a statement that the form will be filed as a permanent part of the medical record.
ii)Follow the process outlined in hospital/skilled nursing facility policy or medical staff bylaws, rules and regulations for adding forms to the medical record.
h)All facilities should educate their physicians on the importance of concurrent documentation within the body of the medical record to support complete, accurate and consistent coding.
i)Communication should be provided to the medical staff that coders or representatives of Health Information Management or Quality Resource Management will query physicians when there are questions regarding documentation for code assignment. This query will be documented and will require physician signature.
ii)Administration and medical staff leadership must support this process to ensure its success.
5.Coding Summary
A coding summary must be placed within the medical record of all skilled nursing discharges.
b)A coding summary must contain all reported ICD-9-CM diagnosis and procedure codes, and their narrative descriptions, patient identification, and admission and discharge dates. The summary may also include discharge disposition.
c)The coding summary should be either a system generated abstract or handwritten codes on the face sheet.
d)The summary must be kept as a permanent part of the medical record.
e)It is required that the Health Information Management Director ensure that the coding summary has been officially approved by the medical staff to be included as a permanent part of the medical record.
i)The coding summary should include a statement that the form will be filed as a permanent part of the medical record.
ii)Follow the process outlined in hospital/skilled nursing facility policy or medical staff bylaws, rules and regulations for adding forms to the medical record.
6.Data Quality Application
Coders must not:
c)Add diagnosis codes solely based on test results;
d)Misrepresent the patient’s clinical picture through incorrect coding or adding diagnosis/procedures unsupported by the documentation for any reason. Each facility must have a process in place to identify appropriateness of services and/or coverage issues before the service is rendered.
e)Report diagnoses and procedures that the physician has specifically indicated he/she does not support.
7.Minimum Data Set (MDS) Completion
The HIM Director and MDS Coordinator should establish a protocol for completing Section I.3 of the MDS. It is the responsibility of the HIM coding staff to assign ICD-9-CM codes for completion of Section I.3. Use the following references when completing Section I.3:
HCFA’s RAI Version 2.0 Manual, Chapter 3; MDS Items, Section I: Disease Diagnoses
The Company’s SNF PPS and Consolidated Billing Transition Manual, Section D: Health Information Management Services
8.MDS/RAP Documentation Requirements
Each electronically submitted Minimum Data Set (MDS) must be printed and maintained as a permanent part of the patient’s medical record. In addition, all caregivers involved in the completion of each MDS must sign the printed paper MDS. This includes any HIM individuals who participated in assigning codes on the MDS. Confirmation of each electronic MDS submission should be maintained as part of the facility’s business records. These do not have to be a permanent part of the patient’s medical record but can be maintained with the medical record if desired. When applicable, any Resident Assessment Protocol (RAP) generated must also be maintained as a permanent part of the medical record.
9.Facility Coding Reviews
Internal (or external) coding quality reviews must be completed on a regular basis by each facility.
a)Reviews should include review of the medical record to determine accurate code assignment with subsequent comparison with the UB-92 claim form to determine accurate billing.
b)Findings from these reviews must be utilized to improve coding and medical record documentation practices and for coder and physician education, as appropriate.
10.Unique Payer Requirements
Each facility must state, in writing, in their policy and procedures that coders will be oriented about and aware of individual payer contracts that contain specific coding and reporting requirements.
a)It is recognized that payers in various states may utilize coding guidelines that do not comply with those issued by the cooperating parties (Source: Practice Brief on Data Quality, American Health Information Management Association (AHIMA), Chicago, Illinois, February 1996).
b)Each organization must develop and maintain, in writing, policies and procedures that document the coding guidelines or coding requirements of a specific payer.
c)Health Information Management should be involved during contract negotiations with third party payers when coding guidelines are addressed.
d)Written department procedures must also include how coding conflicts with payers are addressed. Since most facilities deal with many different payers who issue varied guidelines, coding issues with high volume payers should be addressed first.
11.Claim Denials
Written policy and procedures must require that employees responsible for the final code assignments will review all claims denied (in part or total) based on codes assigned. Documentation must be maintained on claims denied in part or total due to discrepancies in coding.
12.Business Office/Patient Accounts
A written policy must be developed with the business office or patient accounting which prohibits changing/resequencing of codes by patient accounting personnel without review by the coder.
13.Policy Compliance Monitoring
Compliance with this policy will be monitored during reviews by the Health Information Management Services Department and the Company Internal Audit & Consulting Services Department.
b)It is the responsibility of each facility’s administration to ensure that this policy is applied by all individuals involved in coding/claims processing of inpatient services.
c)Employees who have questions about a decision based on this policy or wish to discuss an activity observed related to application of this policy should discuss these situations with their immediate supervisor to resolve the situation.
d)All day-to-day operational issues should be handled locally, however, if confidential advice is needed or an employee wishes to report an activity that conflicts with this policy and is not comfortable speaking with the supervisor, employees may call the toll-free Ethics Line at 1-800-455-1996.
REFERENCES:
Coding Clinic for ICD-9-CM is the official publication of ICD-9-CM coding guidelines and advice as designated by four cooperating parties: American Hospital Association (AHA), American Health Information Management Association (AHIMA), Health Care Finance Administration (HCFA), and the National Center for Health Statistics (NCHS).
Medicare Manual, Section560, Completion of Form HCFA-1450 (UB-92) for Inpatient and/or Outpatient Billing.
Practice Brief on Data Quality, American Health Information Management Association (AHIMA), Chicago, Illinois, February, 1996.
Steps to Coding with ICD-9-CM, Long Term Care Module, 6th printing, California Health Information Association (CHIA), February 1997.
Federal Register, Department of Health and Human Services, Health Care Finance Administration, Washington, DC, December 23, 1997.
Attachment A
Commitment to Data Integrity
One of the important philosophies of the Company is the commitment to conduct our business with integrity and always render our services on a highly ethical level.
This philosophy embraces the following principles related to coding:
1.We have great confidence in our employees and their commitment to collect, manage and report data in an unbiased, honest and ethical manner.
2.We believe that diagnosis and procedure coding should be governed by Official Coding Guidelines and that all codes mandated by the guidelines should be assigned and reported. Adherence to guidelines will promote consistency and accuracy of coded data in individual facility and company databases. The Company policy is that ICD-9-CM diagnosis and procedure codes and CPT procedure codes must be correctly submitted and will not be modified or mischaracterized in order to be covered and paid. Diagnoses and procedures will not be misrepresented or mischaracterized by assigning codes for the purpose of obtaining inappropriate reimbursement.
3.We believe that the diagnosis reported by the physician as the reason for the encounter or visit and the codes reported must be consistent.
4.We believe that the procedural codes reported should accurately reflect the procedures performed during the encounter as documented by the physician.
5.We are committed to providing the support needed to effectively classify our patients. Support provided to the Company’s facilities includes coding seminars, training tools, group purchases of products at discounted rates, publications and nosology support.
Attachment to HIM.COD.010