As a result, written codes of conduct or ethics can become benchmarks against which individual and organizational performance can be measured. Additionally, a code is a central guide and reference for employees to support day-to-day decision making.
A code encourages discussions of ethics and compliance, empowering employees to handle ethical dilemmas they encounter in everyday work. It can also serve as a valuable reference, helping employees locate relevant documents, services and other resources related to ethics within the organization. These are all questions that should be answered in your compliance program.
Conduct periodic inservices to reinforce understanding of the procedures. When documentation deficiencies are identified, educate the physicians on improving their documentation. Clarify conflicting or ambiguous information with the physician. When clarification or additional information is obtained from the physician, make sure this information is subsequently documented in the medical record.
The physician may respond to the coder's query verbally or via an exchange of notes, then the coder assigns the code based on this exchange, but the physician never adds the information to the medical record. Thus, the medical record documentation does not support the code assignment. Provide education outside the HIM department. Educate ancillary departments on the importance of documentation to support medical necessity of ordered tests and on the need for annual updating of the chargemaster.
Since coding accuracy depends on the quality and completeness of physician documentation, physician education on documentation requirements is especially critical. Educate the business office staff on coding processes and in turn, invite them to educate your department on the billing process, including claims rejections and appeals. Make sure to document all internal and external training, including who was trained, what they were trained on, and the dates of training.
Special training programs should be designed to target areas found to be deficient during an internal or external audit. Communication Procedures for communication of changes in regulatory requirements should be established.
A procedure needs to be in place to assure that changes or additions to rules and regulations are communicated to all affected staff. This includes changes that may be contained in publications, such as provider bulletins, that have not been regularly disseminated to the coding staff in the past. You will need to establish a mechanism to assure that memoranda or regulatory issues and provider bulletins are disseminated to all affected staff.
Maintain an up-to-date index for this manual so information is easily accessible at all times. Establish mechanisms for all staff to be updated on changes before the effective date of the change. If you disseminate a memo describing a revised policy or procedure change, ask staff to sign the memo acknowledging their receipt of the information.
Keep the memo and staff signatures on file. Make sure there is a process within your organization for employees to report potential fraud, including any pressures being placed on them to code improperly. Auditing and Monitoring Evaluate your internal coding practices and assure they are consistent with coding rules and guidelines.
Examine your operations with respect to all potential risks and institute appropriate safeguards and compliance controls. Don't just focus on the current "hot issue" in the press.
If you have developed facility-specific coding guidelines, make sure they are not in conflict with official guidelines. Monitor coding accuracy through periodic audits. A concurrent review allows you to identify errors and correct them before submitting a claim. Keep in mind that no one expects a zero percent error rate. Mistakes are okay as long as they truly are mistakes and actions are taken to prevent their recurrence.
These internal audits may indicate problem areas requiring more intensive review and corrective action. Review a statistically valid, random sample of cases in order to determine whether the problem is an isolated case or one that occurred during an isolated time period; or if it is a widespread, ongoing problem.
Interview staff to find out more information about how the particular billing or coding practice in question got started e. Was it adopted after attending a particular seminar?
Also, perform a trend analysis. Have there been any significant changes in case mix or coding practices? Have any DRGs that show substantial increases in the numbers of cases been assigned to them? Appeal all denials you believe to be inappropriate, even if only small amounts of money are involved.
Use information gleaned from patterns of errors or denials to educate staff. Monitor payers' changes of your codes or downcoding of claims for frequency and patterns. Correct any errors in your coding and billing practices identified during this review to prevent future denials.
Cite official sources to support your position. Follow up on the issue until you have received a response from the payer.
High denial rates or repeated coding or billing errors could increase your risk of being audited. Make sure overpaid, as well as underpaid, claims are submitted to the fiscal intermediary.
If you only submit adjustments for the claims in which you are seeking higher reimbursement, you could be charged with fraud. The investigators can claim that you were aware of instances in which you were overpaid, but you failed to return the overpayment to the payer. This can be viewed as a "willful intent" to defraud the government. A good external audit can help you evaluate your risk objectively and produce recommendations for implementing a proactive approach to correct any problems.
Furthermore, it can help promote physician education and awareness, a focus on documentation issues, and coder training. Just remember to select an audit firm carefully. There are many firms out there, and just like in any other business, their services vary greatly in quality. Select a firm who can perform an unbiased review -- which means they have no incentive to maximize reimbursement.
Check the firm's references. The ideal choice would be a firm with expertise in these types of risk evaluation, such as previous experience in developing compliance programs for healthcare organizations.
Physicians' offices should also consider hiring an outside consultant to perform a review of internal control procedures and of records associated with coding, billing, record retention, and collection procedures. Audits should be conducted only under the direction of legal counsel so that findings are protected under the attorney-client privilege. Data Monitors for Compliance MedPar billing data can be used to identify hospitals with coding or billing practices that fall outside comparative norms.
A hospital's billing data can be compared to national, state, and regional norms to determine significant variations. Variations are not in themselves indications of abusive or fraudulent coding practices, since the norms themselves may represent inaccurate coding. They do, however, identify hospitals that appear "different" from their peers. This may be an indication of DRG miscoding leading to inappropriate reimbursement for inpatient care, or there may be a valid explanation for the variation.
The challenge for the HIM professional is to identify the variations, determine the validity of the coding practices represented by the data, and document circumstances resulting in unexpected variations. Figures represent an analysis of one state's MedPar data. The 15 hospitals have been divided into three groups of five hospitals.
These three groups represent a low light blue , median medium blue , and high dark blue peer group within the state for each monitor. There are two lines on each graph: one representing the state norm, the other representing the national norm. Percentages are listed as whole numbers except on the graph indicating the percentage of change in case mix index.
Hospitals with fewer than 10 cases per DRG, DRG pair, code, or code pair as represented by the title of the graph have been excluded percentages appear magnified when small numbers are used. Health information management departments should establish specific data monitors to determine how they compare to national, regional, and state norms.
Currently, changes in case mix index and the ratio of complex to simple pneumonias appear to be two areas under investigation. Problem areas identified following an audit of coding practices may also represent areas of concern. These audits may be performed either internally or by a qualified external auditing company. Data monitors, therefore, should be established for all areas under scrutiny by investigators as well as areas identified as problematic at the hospital level.
Significant variations should be investigated to determine if there is a valid explanation. Changes in case mix index can be the result of many factors. For instance, the addition of services such as open heart surgery, orthopedic surgery, or the addition of a new physician to the medical staff can result in a significant increase in case mix index from one year to the next.
Shifts in volumes of certain DRGs may also cause increases in case mix index. This can result in a variation in the percentage of change in case mix index when compared to national, regional, and state norms. If your data analysis reveals a reasonable explanation for an aberration in coding or billing patterns, document this explanation, along with the official sources that support it, for evidence if you should become a target of a fraud investigation.
Figure 3 represents the percentage of change in case mix index from fiscal year to fiscal year If the coding is accurately reflected by the case mix, determination of the underlying cause should be identified and documented.
Were new services added? Did a new physician with a high volume of patients join the medical staff? Meet with divisional leaders to ensure the policies and procedures are feasible. Look for a program that allows custom certifications for your employees. Being able to create a custom quiz gives you the power to control the content your employees remember most. Determine the best format of policies for your audience.
Ensure the program you use allows flexibility with folders and organization. Finding a program with permission controls will help reduce clutter for your end users. Finding a program that sends alerts to the right people should be a main priority. Notifications should include task-alerts, over-due notifications, and renewal notices to name a few.
Automating this step can increase efficiency. Programs that send automatic alerts, allow a central area for discussions, and provide workflows can save time during the creation of policies, as well as during the audit process. Visit our resource library for industry best practice tips and tools and for case studies on how our software has helped clients in your industry. Let us show you how Policy Management Software will strengthen your compliance program.
About Us Resources Careers Support. Compliance with Policies and Procedures Establishing effective policies and procedures does not begin and end with regulations. Determine the best format of policies for your different audiences. Set deadlines for each policy and procedure to be acknowledged. Involving others, even if just for a 30 minute interview surrounding a policy, ensures that the new policies: Are not misunderstood Use the correct terminology Make sense to the employee.
Include a contact number and email address within their reminders in case they have questions. Download Policy Management WhitePaper. Industries Served.
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