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Guest Post: Creating an inpatient coding compliance plan

Rose Dunn

Rose Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

To limit exposure to claim denials and external reviews, the best safeguard for a facility is a robust, effective internal coding compliance policy, plan, and program.

Begin by reviewing any existing coding policies and procedures to determine whether they are consistent with the organization’s compliance plan, as well as the latest Official Guidelines for Coding and Reporting. If your department lacks compliance policies and procedures, excellent resources are available at JustCoding, ACDIS, AHIMA and the Hospital Corporation of America.

A facility’s coding compliance plan may be a subsection of the policy. If you format your compliance plan as a subsection, the document should be labeled “coding compliance policy and plan.” The plan component should be much more detailed and include the specifics of what, when, and how often. Each organization should tailor its coding compliance plan to its organization.

When developing a new coding compliance plan, managers should begin by asking these questions:

  • Why am I establishing a plan?
  • What will I review?
  • How will I select a sample?
  • How will I assess accuracy?
  • What action will I take when the results are known?
  • How will I monitor progress?

The coding manager should collaborate with the compliance officer in developing the plan. Some components that should be considered when you create your plan are:

Purpose: The purpose of the XYZ Hospital Compliance Plan is to improve the accuracy and integrity of patient data, ensure minimal variation in coding practices, serve as a conduit to improve provider documentation in the electronic patient record, and support XYZ Hospital’s ability to receive its entitled reimbursement for the services it and its providers provide.

Expectation: Staff (employees and, when applicable, contracted staff) will strive to maintain the highest level of professional and ethical standards in the performance of their coding duties. Staff will be trained and oriented in all applicable federal and state laws and regulations that apply to coding and documentation as relates to their positions.

Adherence to these guidelines is imperative. Where any questions or uncertainty regarding these requirements exists, it is the responsibility of the employee to seek guidance from a certified coding specialist, health information administrator, or another qualified coding professional. Staff will be familiar with prohibited and unethical conduct that relates to coding and billing as outlined in the facility compliance plan. Staff will comply with AHIMA’s Code of Ethics.

Education:

  • All coders, billers, and providers will receive orientation and training in the fundamentals of compliant coding and billing. Continuing education will be provided in the form of handouts, memos, journals, in-services, and formal education as available and approved. To keep up with changes in regulatory requirements, coding changes, and proper coding procedures, it is the staff member’s responsibility to further his or her knowledge by reading all handouts, memos, and journals provided, and actively participating in available in-services and formal education workshops.
  • All coders, billers, and providers will receive training in coding, documentation, and billing compliance issues on an annual basis or more frequently as need dictates. The training will be coordinated by the coding compliance subcommittee in conjunction with or in addition to training provided by the compliance office.

Coding resources: Coding staff shall have access to the following resources to facilitate their coding duties:

  • Encoder
  • Computer with dual monitors
  • Coding books: ICD-10-CM for diagnoses and ICD-10-PCS for inpatient procedures; other reference materials will be maintained in the coding manager’s office

Coding conventions and guidelines: The guidelines and conventions to be followed for codes to be reported on claims will be:

  • Coding Clinic published by the American Hospital Association
  • Official Guidelines for Coding and Reporting published by CMS and the National Center for Health Statistics

Editor’s note: This article was originally published in JustCoding. Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. This article is excerpted from JustCoding’s Practical Guide to Coding Management.

 

From the Forum: Using pediatric nursing notes for query creation

From the ACDIS Forum

From the ACDIS Forum

Nursing notes cannot be used for coding and billing purposes. This does not mean, however, that they’re worthless for CDI purposes. Often times, CDI specialists neglect reviewing this documentation because they know it can’t be coded. This is a mistake.

“Often times, it’s the nursing notes that will support queries for encephalopathy, delirium or other altered mental status conditions,” says Karen Bridgeman, MSN, RN, CCDS, CDI educator at the Medical University of South Carolina in Charleston.

While nursing notes can help with clinical indicators to support a query with patients of all ages, nurses’ documentation helps a couple of pediatric-specific diagnoses, for instance, thrush.

“One thing I’ve noted a few times is that nursing usually documents clinical indicators of thrush. The doctor orders Nystatin, but doesn’t document what he/she is treating,” Claudine Hutchinson, BSN, RN, CDI specialist at the Children’s Hospital at St. Francis in Tulsa, Oklahoma, says.

With sticky diagnoses such as malnutrition – an especially difficult diagnosis in pediatrics – nursing notes also often provide valuable information on the patient’s body mass index (BMI), height, and weight. Additionally, the nursing notes often provide clinical indicators to support clinical validity of an already present diagnosis of malnutrition, according to Laurie Prescott, RN, MSN, CCDS, CDIP, CDI education specialist at HCPro in Danvers, Massachusetts.

“Malnutrition in children is based, in part, on their failure to meet developmental milestones and deviations related to their z-score and the pediatric BMI scale,” Allen Frady, RN, BSN, CCDS, CCS, CDI education specialist for BRL Healthcare in Middleton, Massachusetts, said in response to a question in CDI Strategies.

If the nursing documentation supports a diagnosis of malnutrition based on unique pediatric criteria, then a CDI specialist can use that information to support a query to the physician. Often, nurses record the information used to calculate BMI during the initial physical assessment.

Nurses also often document the present on admission (POA) status of pressure ulcers during initial assessments. Since pressure ulcers fall under the hospital-acquired conditions banner, it is vital to document their POA status. If a physician documents a pressure ulcer, check the nursing documentation for its status upon admission.

We work with our [providers] during rounds to be sure that POA status is documented for any pressure ulcers documented by nursing on the admission assessment,” Jackie Touch, RN, MSN, CCM, CDI specialist at CHOC Children’s in Orange, California, says.

Nursing notes can also provide a valuable education entry point for CDI specialists. “In some instances, it may be as simple as showing the physicians where they can access the nursing documentation. “The physicians did not know how or were unable to view the nursing flow sheets,” at Wake Forest University Baptist Medical Center before the CDI helped address the problem, says Melinda Matthews, RN, BSN, CCDS, manager of inpatient clinical documentation excellence at Wake Forest Baptist Health, which includes Brenner Children’s Hospital in Winston-Salem, North Carolina, in an ACDIS Q&A.

Even though coders cannot use the nursing notes for coding purposes, Prescott advises working the nursing documentation into your regular chart review process.

“[Nursing notes] often assist in understanding the patient’s baseline conditions, and often help us to identify any secondary diagnoses not mentioned in the provider’s initial assessment,” Prescott said in a response to a question in CDI Strategies.

Prescott also advises educating the nursing staff about the usefulness of their documentation in supporting clinical validation and identifying missing diagnoses and opportunities for clarification. The nurses can be a valuable asset in reaching CDI goals, so educate them accordingly, Prescott says.

Editor’s note: This article’s content was taken largely from recent posts on the ACDIS Forum. To participate in the Forum, click here. If you have any questions regarding this or the forum in general, please email ACDIS Editor Linnea Archibald at larchibald@acdis.org.

 

 

Book Excerpt: Review all charts to maintain a compliant CDI program

Trey La Charité, MD, FACP, SFHM, CCDS

Trey La Charité, MD, FACP, SFHM, CCDS

If at all possible, CDI programs should review all hospitalizations in a facility for documentation improvement opportunities. And all charts truly means every chart, including every insurance product, regardless of reimbursement mechanism (i.e., by MS-DRG or per diem), including the no-insurance and charity cases. The reason for this directive is multifaceted. First, reimbursement certainly is not the only purpose of a CDI program’s efforts. Even if a particular payer reimburses on a per-diem (per-day) basis or by a different DRG system (i.e., APR-DRGs), meaning there may not be any reimbursement benefits to improved documentation, CDI efforts still offer significant gains.

In particular, every payer employs some form of risk adjustment methodology to compare the outcomes of care between different providers. In other words, a facility’s providers look better to an insurer if they achieve the same results as a competing facility’s providers but do so caring for sicker patients.

Second, the need for a particular patient’s hospitalization must be justifiable. It doesn’t matter how many high-dollar diagnoses a CDI professional identified in the medical record if the payer – be it Medicare or private insurer – denies the claim. The sicker the patient is – both in fact and on paper – the harder it is for an auditor or a payer to justify that the patient should never have been admitted at all or that the patient should have been cared for in observation as opposed to being admitted as an inpatient.

If a CDI program is understaffed and simply does not have the resources to review all charts, program goals should evolve such that more than just the Medicare cases are reviewed. In other words, a CDI program should not be reviewing only Medicare patients.

If a CDI program reviews only Medicare cases, the government and the Office of Inspector General (OIG) believe that hospitals preferentially targets Uncle Sam’s coffers. Don’t increase your facility attractiveness to those who are looking for additional targets. By reviewing all payers, facilities set the precedent that increased reimbursement from CMS is not the only goal of a CDI program.

Editor’s note: This excerpt was taken from the CDI Field Guide to Denial Prevention and Audit Defense by Trey La Charité, MD, FACP, SFHM, CCDS.

Guest Post: An obligation to report noncompliance

Rose Dunn

Rose Dunn

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

One of the many coder/CDI obligations is to report noncompliant activities. Your employer’s compliance plan may direct you to report these noncompliant observations to the compliance officer or a compliance hotline.

When you report your observations, you may do so anonymously or by identifying yourself. It is your decision which approach you take, but regardless, you still have the obligation to report.

Commonly reported coding-relating issues are:

  • Documenting services long after the service was provided and possibly never provided
  • Routinely reporting high-level evaluation and management or MS-DRG codes (upcoding) when the documentation does not support the high level
  • Failure to code to the highest level of specificity when the documentation is present
  • Queries that encourage or lead a physician to add documentation which would increase the level of reimbursement for a particular case
  • Adding charges to a claim for services provided
  • Providing services that are not medically necessary

When a coder/CDI specialist observes actions inconsistent with quality healthcare, the more detail provided to the compliance officer will help in the investigation. Depending on investigation findings, major, minor, or no changes may result. Sometimes, actions observed may appear inappropriate, but upon investigation, the actions were consistent with clinical practice.

For example, a coder/CDI specialist may consider the actions of another staff member to be too zealous in optimizing the codes to achieve higher reimbursement. The term optimization is defined as a procedure used to make a system or design as effective or functional as possible.

When coders “optimize” the coding process, they attempt to make coding for reimbursement as accurate as possible. This process may involve querying the physician for clarification of conditions or augmenting conditions documented. If done in a nonleading way, the organization will obtain the highest entitled reimbursement.

When the investigation illustrates the need to make changes, you will probably see activities such as reeducation, updating of policies, and possibly the removal of staff members.

Qui tam

Unfortunately, there are times when an individual reports legitimate compliance concerns and does not see actions being taken to correct the concern. In these situations, a person may wish to “blow the whistle” and contact an agency outside of the organization to file a lawsuit. This type of lawsuit is known as a qui tam lawsuit.

Qui tam lawsuits are a type of civil lawsuit whistleblowers bring under the False Claims Act, a law that rewards whistleblowers if their qui tam cases recover funds for the government. Qui tam is an abbreviation of the Latin phrase meaning “who as well for the king as for himself sues in this matter.”

Qui tam cases are different from other types of lawsuits, such as those involving personal injuries, because the person bringing the lawsuit is not the one who has been harmed.

A recent example of qui tam is the South Florida case where physician Mario Baez, a partner in a physician practice, turned whistleblower on his partner when he determined that his partner was submitting fraudulent claims. Nearly all the patients seen at IM Medical and Lake Worth Medical were diagnosed with a serious but rare spinal disorder called ankylosing spondylitis, when only 1 in 1,000 people truly have this disorder, according to Baez. The disorder increased the risk score for the physicians who were participating in a Medicare Advantage health plan reimbursement arrangement with Humana. The higher the risk score, the greater the reimbursement. The interesting twist on this qui tam is that Baez was not just whistleblowing on his partner but also on Humana. Humana should have been able to detect this fraudulent activity.

Taking a qui tam action requires much consideration, because often the whistleblower is identified during the legal proceedings. Having legal counsel guidance will be beneficial. If the case is lost, the situation can be embarrassing.

However, if the case is won, there may be financial rewards for the whistleblower depending on how much the whistleblower’s details of the situation contributed to the success of the suit. Regardless, following your convictions to surface inappropriate care should result in better care for patients thereafter, and that is the right thing to do.

Editor’s note: Dunn is a past president of the American Health Information Management Association and recipient of its 1997 Distinguished Member and 2008 Legacy awards. In 2011, she served as the interim CEO of AHIMA and received a Distinguished Service Award from its board of directors. Dunn is the chief operating officer of First Class Solutions, Inc., a health information management consulting firm based in St. Louis. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries. For questions please contact editor Amanda Tyler at atyler@hcpro.com. This article is excerpted from JustCoding’s Practical Guide to Coding Management.

Sunday Reading: Compliance involvement in CDI efforts

The Physician Queries Handbook

The Physician Queries Handbook

CDI programs bear the weight of potentially great benefit or potentially great risk for their organizations, depending on the focus and compliance of their query efforts. It is worth mentioning, however, that CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.

Ongoing compliance department involvement can help ensure CDI staff structure queries in a compliant manner. Compliance staff can advise the CDI staff members as to whether templated queries are acceptable, too. Such involvement helps ensure that your CDI program meets the doctrine and spirit of the existing regulations.

Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance.

In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.

Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

Medicare Compliance Forum includes CDI focus

MCF includes sessions for CDI professionals.

MCF includes sessions for CDI professionals.

If you just can’t get enough of former ACDIS CDI Education Director Cheryl Ericson, MS, RN, CCDS, CDIP, consider joining her and fellow speakers Deborah Hale and John Zelem for the 2015 Medicare Compliance Forum in Charleston, South Carolina, October 27-28. 

The 2015 Medicare Compliance Forum addresses the ever-changing reimbursement landscape and has six tracks to choose from (three each day),  covering Medicare billing and compliance, as well as challenges facing case managers, clinical documentation improvement specialists, utilization review professionals, and more. Here’s a look at the CDI-related sessions being offered.

Document, Document, Document: Enhance Documentation to Drive Meaningful Data
Cheryl Ericson, MS, RN, CCDS, CDIP

Providers need more than just being told to “document” because not all documentation in the medical record is created equal. Most medical records contain pages and pages of words, but much of this text is repetitive and doesn’t translate into meaningful codes, which in turns fails to support medical necessity. This session will take a look at when documentation has meaning by exploring the general concept of medical necessity and its relationship to coded data.

Is Your Readmission Problem Really a Documentation Problem?
Cheryl Ericson, MS, RN, CCDS, CDIP

This session will present an overview of the impact of coded data on CMS quality initiatives, which are also known as pay-for-performance. Participants will be introduced to the CMS quality initiatives of the Hospital Value-Based Purchasing Program, the Healthcare-Acquired Condition Reduction Program, and the Readmission Reduction Program, and how CDI efforts can support accurate reporting of these measures based on administrative data. Key documentation issues associated with the CMS quality initiatives will be presented.

Clinical Documentation Improvement and the Quality Mandate
Deborah K. Hale, CCS, CCDS

Value-based purchasing (VBP) is an important step to revamping how healthcare services are reimbursed in the Medicare program, and it is emerging in the commercial insurance market. Clinical Documentation Improvement for risk adjustment and accurate representation of the patient’s precipitating factors are critical to financial and marketing success. This session will demonstrate Clinical Documentation Improvement targets for risk adjustment and for achieving success with VBP initiatives.

The Role of CDI and the EHR in Supporting Medical Necessity
John Zelem, MD, FACS; Cheryl Ericson, MS, RN, CCDS, CDIP

CDI specialists are often tasked with reviewing the medical record to ensure documentation is comprehensive. However, the use of EHRs can minimize the utility of the health record as documentation often becomes generalized and repetitive. CDI specialists and coders face challenges associated with organizational implementation of meaningful use (e.g., problem lists, computer physician order entry, and the ability of providers to copy and paste documentation). Explore some of the challenges associated with provider documentation resulting from the increased use of technology.

Sunday Reading: Compliance involvement in CDI efforts

The Physician Queries Handbook

The Physician Queries Handbook

CDI programs bear the weight of providing a potentially great benefit or a potentially great risk for their organizations, depending on the focus and compliance of their query efforts. CDI programs should include input from their facility compliance officer and legal counsel at various stages of implementation and growth.

Ongoing compliance department involvement can help ensure that CDI queries are structured in a compliant manner and can advise the CDI staff members as to whether query templates are acceptable. Such involvement will help guarantee that your CDI program meets the doctrine and spirit of the existing regulations.

Since CMS represents the nation’s largest healthcare payer, many CDI programs get their start in conducting record reviews for Medicare patients and/or top diagnosis target areas. However, the goal of improved documentation and patient care should be consistent across payers and disease type, not just improved healthcare documentation for patients who happen to have government insurance. In addition, the goal of improved documentation and patient care should not focus only on high-cost services such as acute respiratory failure or any other special circumstance. When there is a lack of consistency in policies and procedures, for example, reviewing Medicare and not private payers, the risk for potential misuse and abuse increases.

Editor’s Note: This excerpt was taken from The Physician Queries Handbook by Marion Kruse, MBA, RN.

Join us on the podium at the 2015 Medicare Compliance Forum!

Pic 6

HCPro is currently seeking speakers to present at the 2015 Medicare Compliance Forum, to be held October 27–28, 2015, at the Marriott Charleston in Charleston, South Carolina.

Dear healthcare professional,

HCPro is currently seeking speakers to present at the 2015 Medicare Compliance Forum, to be held October 27–28, 2015, at the Marriott Charleston in Charleston, South Carolina.

Is that special person you or a colleague?

We seek speakers to present on all aspects of Medicare compliance, case management, utilization review, patient status, and the revenue cycle. Hot topics from the 2014 Medicare Compliance Forum include:

  • The latest changes to IPPS and OPPS regulations and their impact on the audit landscape
  • What the 2-midnight rule means for patient status and medical necessity
  • Changes to observation services and the impact of Condition Code 44 on revenue
  • Guidance on Part A to B rebilling
  • Implementing policies to receive accurate payment for packaged and separately billable labs
  • An update on the current OPPS system and the impact of the new comprehensive APCs on Medicare claims
  • Strengthening your utilization review committee by reviewing real-world examples of successful reviews and fully understanding the Conditions of Participation
  • Engaging your physician advisors to strengthen your utilization review committee determinations
  • Leveraging the expertise of clinical documentation improvement specialists

Note: If you don’t see your hot topic listed here, please write and let us know what expertise you can bring to the podium! Original ideas are welcome.

Submission form and deadline
Please click this link: http://app.keysurvey.com/votingmodule/s180/f/727062/56e6/, complete the form, and submit it to us no later than end of day Monday, March 16, 2015. Please be sure to complete all the fields. Leaving the form open for a lengthy period may cause it to “time out,” so you may wish to draft your submission in a separate word document and paste in the appropriate fields to ensure proper transmission. Speakers are welcome to submit more than one session, but must fill out a separate form for each submission.

HCPro will waive admission fees to the Medicare Compliance Forum for all selected speakers and co-speakers. Conference sessions are typically one hour in length, and selected presenters will be expected to submit PowerPoint materials at a later date.

We look forward to hearing from you! If you’d like more information or wish to discuss a speaking topic, please e-mail Editor Jaclyn Fitzgerald at jfitzgerald@hcpro.com and we’ll set up a convenient time to speak by phone.

Q&A: Addressing a peer’s non-compliant query

Go ahead, ask us!

Go ahead, ask us!

Q: What should I do if I see a non-compliant query in the chart? Should I remove it, let my co-worker know, or just leave it in the chart?

A: Addressing non-compliant queries can be tricky. The best course of action would be to share your concerns with your supervisor who can then either confirm your perception of the query being non-complaint or could let you know why he or she feels the query is acceptable. Ask your manager or supervisor to go over any internal query policies to help you better understand your facility’s compliance parameters.

Most facilities have standard query policies and procedures which reflect national standards (such as the 2013 AHIMA/ACDIS “Guidelines for Achieving a Compliant Query Practice” brief). They also have processes in place to help co-workers handle questionable query processes.

If there are no policies and procedures in place (or if you and your coworker are only the two CDI staff querying physicians at your facility) you may want to review the latest query practice information together and approach whatever management team is in place to develop such policies yourselves.

If the query is truly non-compliant, I would definitely want the supervisor to address it rather than you doing so on your own. It may be that the individual needs additional training or it may become a potential performance issue. In which case your manager or supervisor needs to know about the situation and may even need to have a documented conversation with the CDI team member who left the query.

You wouldn’t want to remove the query. The physician may have already reviewed it and responded in his or her progress note. If auditors or internal staff later question where that diagnosis came from, no query trail would exist and you may not be privy to those subsequent questions. If the supervisor or program manager determines the query was indeed non-compliant he or she may need to also circle back to discuss the situation with the physician and/or coding team.

Book Excerpt: CDI in the Regulatory Environment

The Physician Advisor's Guide to CDI.

The Physician Advisor’s Guide to CDI.

Twenty years or so ago, CDI specialists might have been called record reviewers or had a title associated with “optimizing” the documentation in the medical record. In the course of the MS-DRG implementation and related documentation and coding adjustment payment decreases, CMS indicated in its FY IPPS final rule that there is “nothing inappropriate, unethical, or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment… supported by documentation in the medical record.” And so facilities began to formalize the CDI role.

As benevolent a mission as CDI may seem to have, for many facilities the focus of concurrent physician queries continues to be identifying information to increase reimbursement. When such efforts do not reflect the care provided to the patient or are conducted in a leading manner, these practices could be construed as fraud–particularly when data patterns appear to illustrate inconsistencies with national norms.

Of course, healthcare providers must ensure the financial solvency of their organizations, just as government officials must ensure the solvency of their healthcare funding programs. Both sides of this fiscal conundrum face growing financial frustration as both sides continue to search for an underlying cause to answer the dilemma of expanding healthcare costs.

Nevertheless, when a facility submits a claim to the federal government for payment of activities that were never provided, it risks being accused of False Claims Act violations, investigations by the office of the Inspector General and in some cases prosecution by the Department of Justice.

Editor’s Note: This excerpt comes from The Physician Advisor’s Guide to Clinical Documentation Improvement by Trey La Charité, MD, and  James S. Kennedy, MD, CCS, CDIP.