Coding Policies and Procedures PDF Print E-mail

I. Introduction

Since the onset of health care compliance and the focus on potential violations of the Federal False Claims Act under HIPAA, the quality of coded data for reimbursement is constantly under review. As a result, each health care organization must insure the quality of its coded data. One of the best means for achieving accurate, consistent and reliable data is to develop comprehensive documented internal coding guidelines.

It is more important than ever to have information regarding the specific coding practices which an organization’s coding staff is expected to follow in writing and accessible to all members of the staff. Your coding guidelines will not only serve as a way to steer your coding staff in the right direction, they could also serve to protect you in the event of an audit or investigation.

II. Sources for Coding Guidelines

Official basic coding guidelines for both the inpatient and outpatient settings were developed by the Federal Government. In addition to these basic guidelines, the only officially recognized source for hospital based-coding guidelines is the Coding Clinic published by the American Hospital Association. Coding Clinic Guidelines are fairly comprehensive and date back to 1985, however, they will not address every issue that every coder will encounter in the process of coding. In addition, the officially recognized coding guidelines for CPT coding come from the CPT Assistant published by the American Medical Association. To prevent haphazard coding practices, each organization will need to look to secondary sources or "quasi-official" sources for coding guidance. These include:

  1. The provider’s Fiscal Intermediary
  2. The OIG's Compliance Program Guidance
  3. The ICD-9-CM Coding Handbook published by the AHA (this contains explanations and examples for many of the Coding Clinic guidelines)
  4. The ICD-9-CM Coding Handbook for Physician Practices published by AHA
  5. Applicable versions of the Federal Register (only refer to this document if Coding Clinic has not ruled on an issue – as Coding Clinic will over-rule the Federal Register on particular coding issues)
  6. Guidance from the American Health Information Management Association’s (AHIMA) coding experts for ICD-9-CM and CPT advice or the American Academy of Professional Coders’ (AAPC) coding experts for CPT issues.

III.  Why Develop Comprehensive Coding Guidelines?

The livelihood of every health care organization rests upon correctly coded data. This is true from a basic financial tenant – coding drives reimbursement – as well as a compliance perspective. While all of the resources noted above are excellent resources for various pieces of coding information and guidance, they can be meaningless without the health care organization itself sifting through all of the information and translating it into provider-specific coding guidelines. Essentially, the health care organization needs to develop a dynamic "living" document that reflects official coding guidelines and fills in the blanks with quasi official resources and provider-specific interpretation of how those quasi official resources should be applied by the coding staff of the health care provider.

The use of well-documented comprehensive coding policies will:

  1. Provide consistency, accuracy and reliability of the coded data in a provider’s database;
  2. Assure sound and ethical coding practices; and
  3. Provide back up if coding practices are questioned by the government, payor or other third party.

IV. Who should be involved?

The guidelines should be developed and managed on an ongoing basis by the HIM department representative - usually the coding or data quality manager. This individual should have the final responsibility for finalizing the guidelines, ensuring they are updated and gathering the right individuals and groups together to provide appropriate and necessary feedback into the initial as well as ongoing development process. In addition to the HIM manager, other individuals or groups that should be involved in coding guideline development include:

  1. The Coding Staff– input from this group is particularly key in identifying areas where they may have questions or unclear guidance and need to have clear-cut guidelines for reference.
  2. The Medical Staff– key members of the medical staff in various services should be identified as individuals who will assist the HIM manager in clarifying clinical and documentation concerns. In addition, these individuals can serve as a resource in ensuring that all policies are clinically validated. This concept is discussed in detail below.
  3. The compliance officer– while generally not a content expert (although in a growing number of facilities the compliance officer is in fact also an HIM professional), the compliance officer should be brought into the guideline development process as a "consultant" to put the compliance stamp of approval on the guidelines.
  4. Clinical Committees– the number and specific type of clinical committees within each health care organization will vary. However, these committees, like the Tissue and Mortality Committees, can be used as Clinical Expert references during the guideline development process.
  5. The Medical Staff as a Whole– you will need to develop some guidelines that will apply to your medical staff as a whole – usually because it is already their practice and you are just clarifying the practice via a documented guideline. (i.e. in the case of urosepsis, a medical staff can determine that the term, as used within that organization, signifies sepsis with its origin in the urinary tract.) When you do develop guidelines like this, your medical staff will need to vote on the guideline. And, a record of this vote must be kept within the ‘administrative" section of the guidelines.
  6. Medical Record/HIM Committee– final approval for the guidelines must come from some organized, recognized committee within the organization. Generally, the Medical Record/HIM Committee is the best place for this activity – but, again, this may vary based on the organization. Minimally, this committee must approve the guidelines initially, approve updates on some regular basis, and provide an annual review and re-approval.

V.  How should the guidelines be developed?

The development of Coding Guidelines should follow these steps:

  1. Decide on the format of the guidelines.

    Guidelines may be organized by Medical Service, ICD-9-CM chapter, body system or any other logical format. Once you have determined the format, it should be applied consistently. In addition, depending on the organization, your guidelines may need to address several different types of coding. For example, in the hospital setting, guidelines should be developed for the following types of coding:

    1. Inpatient
    2. Ambulatory Surgery
    3. Emergency Room
    4. Outpatient/Ancillary Services
  2. Identify all coding issues addressed in Coding Clinic or the CPT Assistant and reference them in the guidelines. You do not necessarily need to reproduce the entire guideline (although you may want to). The important thing is that your staff knows that for a particular issue they have looked up, they need to abide by Coding Clinic guidance.
  3. Identify all coding issues not in Coding Clinic, but addressed in other "quasi-official" resources like those mentioned above. Incorporate these references into your guidelines where possible and applicable.
  4. Identify all issues not addressed clearly and comprehensively by any of the sources and develop hospital-specific guidelines for them relying to the extent possible on "quasi-official" sources. This process will be very time consuming, if performed correctly. But remember, that the benefits (in terms of correct billing and compliant coding practices) will definitely exceed any initial costs that may be associated with guideline development.
  5. Clinically validate all organization-specific guidelines before implementation. You can do this by determining which medical specialty, service, or hospital committee would be most appropriate (and willing) to review and validate the clinical significance of each guideline. Ideally, for example, a group of cardiologists should validate any coding policies pertaining to coding cardiovascular diagnoses and procedures. The medical staff is usually the most important clinical component in coding guideline validation. There may be some standing committees in your organization (with physician members) that can apply criteria they use to validate coding guidelines. Some examples are:
    1. Tissue Committee
    2. Transfusion Committee
    3. Mortality Review Committee
    4. Utilization Review/QA Committee
    5. Infection Control
  6. Develop a functional Table of Contents as well as an alphabetical index for the policy manual. If the manual is online, it must be in a permanent format that does not allow the user to make changes. In addition, you should build in a search capability for online policies. This will take the place of the alphabetical index in the manual version. Alphabetical indices can be created using various computer publishing programs. Both the table of contents and the alpha index will make the manual more useful and functional for the user.

VI. What should the content of the Coding Guidelines be?

The outline provided below is an example of content for a hospital coding program, but the outline can be adapted to coding in any setting - keep in mind that it is essential that the policies are specific to the organization. Just as no organization should have a "canned" compliance plan, no organization should have 'canned" coding policies.

  1. Ethical Standards of Coding– your guidelines should reference the AHIMA Standards of Ethical Coding generally (include a copy if possible) and your organization’s Standards of Conduct that apply to coding tasks specifically.
  2. Documentation Policy
    • Cardinal Rule for All Coding: a coder may not code a condition/diagnosis/procedure unless it is clearly documented by the physician.
    • Medical Abbreviations
    • Medical staff approved
    • Process for updating
    • Frequency
    • Type
    • Addition
    • Deletion
    • Change
    • Physician Liaison – role, functions, interface with coding staff
    • Define minimum set for coding and billing purposes
  3. Physician Query Process
    • When it is acceptable to query the physician
    • Criteria for a "clinically valid" physician query
    • Format of the query
    • Peer review of the query process
  4. Auditing Policy(Outline of Information to be addressed)
    • Benchmarking
    • Method of sample selection (random vs. focused vs. both)
    • Number and type of records to be audited
    • Determine target proficiency rate
    • Defining Coding Error (DRG assignment vs. overall data quality)
    • Frequency of audits
    • Interface with compliance staff
    • Follow up
  5. Qualification of Coders and Auditors Policy
    • HIM credentialed staff only as coders/auditors
    • List acceptable credentials for each position
    • Determine minimum number of CE hours in coding-related topics per year
    • Required years of experience

 

  1. Inpatient Coding Policies

    • Coding versus Reporting
    • Establish number of diagnoses and procedures to code
    • Define facility specific diagnoses and procedures to code
    • Specific Diagnostic Policies that should be developed/documented 
      •  Certain Conditions Originating in the Perinatal Period (Chapter 15)
      • Classification of Factors Influencing Health Status and Contact with Health Service (V Codes)
    • Classification of External Causes of Injury and Poisoning (E Codes)
    • Complications of Pregnancy, Childbirth, and the Puerperium (Chapter 11) 
      • Group B Streptococcus Infection
    • Obstructed Labor
    • Diseases of the Blood and Blood-Forming Organs (Chapter 4)
      • Blood loss anemia 
      • Clinical indicators
      • Acute versus Chronic
    • Diseases of the Circulatory System (Chapter 7) 
      • Severity 
      • Congestive Heart Failure
      • Symptoms
      • Pleural effusion
      • Pulmonary edema
      • Coronary Atherosclerosis, CAD and sequencing
      • Cardiac Valve Disorders
    • CVA versus TIA
    • Hypertension 
    • Myocardial Infarctions
      • Specificity 
      • Location 
      • Severity
    • Thrombophlebitis versus Thrombosis
    • Diseases of the Genitourinary System (Chapter 10)
      • Urinary Tract Infection
      • Urosepsis
    • Diseases of Respiratory System (Chapter 8)
      • Pleural effusion vs. symptom of underlying cardiac condition
      • Pneumonia - bacterial vs. NOS vs. aspiration, etc
    • Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders (Chapter 3)
      • Dehydration/Clinical indicators 
      • Principal versus secondary diagnosis
    • Infectious and Parasitic Diseases (Chapter 1) 
      • HIV/AIDS
      • Septicemia
    • Mental Disorders (Chapter 5) 
      • Define the medico-legal significance of psychiatric diagnoses 
      • Emphasize importance of physician documentation
    • Symptoms, Signs and Ill-Defined Conditions (Chapter 16)
      • Define when it is OK to use 
      • No definitive diagnosis
      • Not an integral part of the disease process
      • Symptom, followed by comparing/contrasting diagnoses
    • Discharge Status 
      • Identify process
      • Define staff roles and responsibilities
      • Initial entry
      • Verification prior to billing

  2. Ambulatory Surgery Coding Policies
    • Miscellaneous Diagnostic and Therapeutic Procedures
    • Obstetrical Procedures
    • Operations on the Nervous System
    • Operations on the Endocrine System
    • Operations on the Eye
    • Operations on the Ear
    • Operations on the Nose, Mouth and Pharynx
    • Operations on the Respiratory System
    • Operations on the Cardiovascular System
    • Operations on the Hemic and Lymphatic System
    • Operations on the Digestive System
    • Operations on the Urinary System
    • Operations on the Male Genital Organs
    • Operations on the Female Genital Organs
    • Operations on the Musculoskeletal System
    • Operations on the Integumentary System

  3. Medical Necessity
    • Source of edit
    • Application of the National Correct Coding Initiative Policy
    • Local Medical Review Policy
    • Type of edit
    • Advance Beneficiary Notice
    • Definition of medically unnecessary services
    • Acceptable versus Unacceptable forms
    • Duplicate services
    • Frequency of testing
    • Lack of diagnostic and procedural linkage
    • Mutually exclusive procedures
    • Non-covered services
    • Unbundling of services
    • Screening versus Diagnostic Mammograms
    • Laboratory
    • Radiology

  4. Emergency Room Coding Policies
    • Evaluation and Management Services
    • Define who is responsible for code assignment
    • Facility versus physician billing
    • Linkage
    • Accountability
    • EMTALA (role of coder in identifying potential risk exposure)
    • Triage documentation/use of
  5. Policy regarding outside coding services
    • Require all outside firms to read and sign off on coding policies
    • Require all outside firms to follow coding policies
    • Detail the procedure that will be followed if the policies are not applied
    • How will policies be made available? On line? Hard copy?

VII. Coding Education to Reinforce Coding Guidelines

The OIG has made it very clear that it sees coding and billing as currently the biggest compliance risks for every health care provider. In the OIG's Compliance Program Guidance and in every settlement to date, the OIG has stated that "general compliance education is required for all provider employees, but additional focused training is recommended for individuals in higher risk areas, like coding and billing." In addition to training on basic coding issues, every provider should use their coding policy manual as a basis for ongoing education and training of its coding staff. More importantly, the coding manager should keep records of the education sessions drawn from the coding policy manual and document the content of the meetings as well as who was in attendance. In addition, each coder should be required to take periodic quizzes on different sections of the policy manual. These records will serve as evidence that the coding staff understood and was familiar with the organization's coding manual.

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