2 strategies for coding compliance

By Ken Bradley
April 30, 2014
Body of Knowledge Domain(s): Financial Management

Creating a compliance plan can help protect practice professionals from audits (and the resulting lost revenue) and make the difference between fraud and abuse determinations, according to coding professionals who presented during the on-demand MGMA Compliance Virtual Academy.

To avoid coding compliance problems, professionals recommend these strategies:

Review your clinical clarification process

Success with initiatives such as ICD-10, quality reporting and pay-for-performance programs rely on accurate and specific clinical documentation. Implementation might necessitate an increase in the amount of clinical clarification, or queries, between providers and coders to ensure alignment of clinical documentation and coding. For example, a provider may assume that a coder will apply the visit level to a record, while a coder may assume that the provider will apply the correct coding level to the visit immediately after the patient encounter.

Clarification queries can be applied concurrently, pre-bill or post-bill to help ensure that clinical documentation supports coding.

The clinical clarification query process is a way for practices to ensure that clinical documentation is reviewed to be both complete and compliant.  Coders must ensure that coding captures the intent of the physician as well as all details associated with the patient’s condition, observations and treatment, among others. Clinical documentation is the foundation that supports practices’ revenue cycle and clinical understanding and treatment of patients and should be maintained to provide accurate details to support both.

Implement a compliance plan

Creating a documented compliance plan might make the difference between fraud and abuse determinations from auditors.

Federal, state and even private payers are increasingly ensuring that payment for medical services are accurate and necessary, and they are reviewing payments to locate overpayments or intentional fraud. Violations of billing rules can range from mistakes in billing for what are deemed to be medically unnecessary services to incorrect coding to intentionally coding claims for increased or improper overpayments.  Mistakes are sometimes inevitable, but if practices have a plan that encourages understanding and enforcement of billing requirements, it helps mitigates alleged intentions of fraud. Learn more about the Office of the Inspector General’s (OIG) compliance education materials.

If you have a clear compliance plan that stipulates how often staff is educated on compliance issues, what type of self-assessments will be performed and how compliance issues will be reported, practices can establish a solid foundation for accurate billing and reimbursement.

Training should help providers:

  • Avoid cloned notes
  • Use EHR templates effectively
  • Correct under-coding and over-coding

For example, providers might rely too heavily on EHR templates without making sure to fill in additional details to make sure the record is a “true reflection of the patient’s visit for that day,” says Nancy Enos, FACMPE, CPMA, CEMC, CPC-1, independently contracted consultant, MGMA Health Care Consulting Group.

Enos recommends that administrators offer training so that providers review the template information after a patient visit and edit/remove any information that may affect whether the record represents the actual.
Document the implementation of your compliance plan, such as when and who was trained, and the efforts you took to address a potential compliance issue.

Learn more about proper record documentation, how to create a compliance plan and reducing the risk of an audit in your practice in the MGMA Compliance Virtual Academy, and look out for two more coding compliance tips in part two of this blog.

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Ken Bradley , Vice President of Strategic Planning and Regulatory Compliance, Navicure

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