Leaving 2017 and moving into 2018, three major issues await coders—issues that could be opportunities.
As we now come to the end of another year and look towards the next, what are the big issues for coding professionals? I often think about the new Official Coding & Reporting Guidelines and the changes within. I think about audits and how we fear them, but should instead see them as a necessary support mechanism and function. And I think about coding compliance and how we need it more than ever in our profession.
The Official Coding & Reporting Guidelines are the bread and butter for any coding professional, no matter what credential one holds or what healthcare setting in which one works. Within the “conventions” we’ve seen and heard (and continue to see and hear) concerns with No. 15. Here’s the full description:
Keep in mind that the conventions apply across the whole of the coding classification, as this is critical no matter your setting. Following the Alphabetic Index will help guide you under the conventions and lead to the tabular section to finalize the code selection or assignment. Let’s work more diligently to dissect, understand, and apply the conventions and guidelines, for this can only result in greater coding accuracy and data integrity.
Coding audits have been a part of our industry since the advent of diagnostic-related groups (DRGs) around 1983 and 1984. Audits can be either focused and/or random, the later being a primary choice; they can be either internal and/or external, but having both is ideal. Making staff less fearful of such audits does take communication and transparency. Often the coding staff members are left out of the process or details are not shared or explained to them; this is a big mistake, because it really is a very important piece of the auditing work. Another aspect of audits that can result in concern is when the audit sample size is too large or too small. There should be a volume of records reviewed that truly is representative of the work of the coding staff.
Coding compliance seems to ebb and flow in our industry. Only when there is a really big False Claim Act (FCA) incident related to coding and/or documentation does it get the attention and support that it should. According to the International Compliance Association:
- The term “compliance” describes the ability to act according to an order, set of rules, or request.
- In the context of financial services, business compliance operates at two levels:
- Level 1 – Compliance with the external rules that are imposed upon an organization as a whole.
- Level 2 – Compliance with internal systems of control that are imposed to achieve compliance with the externally imposed rules.
The seven key elements of a compliance program that the U.S. Department of Health and Human Services (HHS) Office of Inspector (OIG) has published are:
- The development and distribution of written standards of conduct, as well as written policies and procedures that promote the hospital’s commitment to compliance (e.g., by including adherence to compliance as an element in evaluating managers and employees) and that address specific areas of potential fraud, such as claims development and submission processes, code gaming, and financial relationships with physicians and other healthcare professionals;
- The designation of a chief compliance officer and other appropriate bodies, e.g., a corporate compliance committee, charged with the responsibility of operating and monitoring the compliance program, and who report directly to the CEO and the governing body;
- The development and implementation of regular, effective education and training programs for all affected employees;
- The maintenance of a process, such as a hotline, to receive complaints, and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation;
- The development of a system to respond to allegations of improper/illegal activities and the enforcement of appropriate disciplinary action against employees who have violated internal compliance policies, applicable statutes, regulations, or federal healthcare program requirements;
- The use of audits and/or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas; and
- The investigation and remediation of identified systemic problems and the development of policies addressing the non-employment or retention of sanctioned individuals.
The OIG and the Health Care Compliance Association (HCCA) this year released a great resource titled “Measuring Compliance Program Effectiveness: A Resource Guide.” For the coding professional, coding company, coding department, physician practice, etc., this really indicates how we have to do more in the compliance arena; we need not to just have a document or pieces of paper referring to compliance and what we’ll do to achieve it, but rather we need to really be effective and confirm that we are effective.
Now is the time to take a look at your coding compliance program/plan, or lack thereof, and take the necessary steps to establish a well-rounded, effective program, and/or reassess your current coding compliance program to determine its true effectiveness and efficiency.
Some will say the three areas I mentioned above are the big concerns for coding professionals, but the optimist in me will tell you that these are actually big opportunities, marking the advent of a time for increased learning and improvement. The Official Coding & Reporting Guidelines, Audits and Compliance are all essential and critical to the coding professional, as they drive accuracy and integrity.
We’re ending one year we can now reflect upon and starting another, so remember that these three areas of the coding profession remain pivotal for ongoing achievement and success!