Professional Coders Role in Compliance

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1 Professional Coders Role in Compliance Sponsored by 1915 N. Fine Ave #104 Fresno CA Phone: (559) Fax: (559) Program Handouts Monday, June 8, 2015 Track One 3:20pm 4:20pm 2015 State Convention and Exhibit Speaker Sally Gibbs, MA, RHIA, CCA, AHIMA-Approved ICD-10 Trainer Copyright California Health Information Association, AHIMA Affiliate

2 California Health Information Association California Health Information Association Professional Coders Role in Compliance June 2015 Sally Gibbs, MA, RHIA, CCS, Epic HIM Manager, Coding and Billing Compliance Sutter Health Disclaimer This material is designed and provided to communicate information about clinical documentation, coding, and compliance in an educational format and manner The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation Copyright California Health Information Association, AHIMA affiliate 1

3 Goal This presentation is designed to introduce how coding professionals can be key players in maintaining an health organization s coding, reporting and billing of patient care services provided. These key roles can be proactive, retrospective, and investigatory. Objectives Understand the definition of a professional coder Review the AHIMA s Code of Ethics and how this can influence a professional coder s role in compliance Gain knowledge of how a professional coder can support a system wide workflow designed to support complaint reporting and billing Understand the professional coder s role in a compliance investigation or audit Copyright California Health Information Association, AHIMA affiliate 2

4 Who Are Professional Coders? Many acronyms: RHIT, RHIA, CPC, CCS P, CCS, CPC H, CHA, CHC, etc. Certifications are valuable Expertise is important Experience is key AHIMA s Code of Ethics AHIMA Standards of Ethical Coding The coding process is affected by complex regulatory requirements, coding professionals are frequently faced with ethical challenges AHIMA s House of Delegates createdthethe Standards of Ethical Coding which reflect ethical concepts from AHIMA s Code of Ethics Copyright California Health Information Association, AHIMA affiliate 3

5 AHIMA s Code of Ethics AHIMA Standards of Ethical Coding are intended d to: Assist coding professionals and managers in decision-making Outline expectations for making ethical decisions in the workplace AHIMA s Code of Ethics AHIMA Standards of Ethical Coding are intended to: Demonstrate coding professionals commitment to integrity during the coding process, regardless of the purpose for which codes are being reported The Standards are relevant to all coding professionals and those managing the coding function, regardless of healthcare setting or AHIMA membership status Copyright California Health Information Association, AHIMA affiliate 4

6 AHIMA s Code of Ethics Where are the AHIMA Standards of Ethical Coding located? cuments/ahima/bok2_ hcsp?ddocname=b ok2_ Or do a web search AHIMA Standards of Ethical Coding Definition of Compliance Compliance: Adherence to the requirements of the Medicare and Medicaid (Medi Cal) laws and regulations and as stated in the Social Security Act and the regulations administered by the Centers for Medicare & Medicaid Services (CMS) and other federal and state agencies. (Also: Corporate Compliance). (Glossary of Compliance Terms, Compliance 101 Second Edition Troklus & Warner) Copyright California Health Information Association, AHIMA affiliate 5

7 Remember The primary focus of reimbursement investigations is checking for correct reimbursement for Medicare patients The mechanisms or rulebooks Centers for Medicare and Medicaid Services (CMS) for reimbursement of healthcare for their patients are: On line Medicare Manual National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) Expectation that healthcare providers follow Official Coding Guidance for ICD and CPT coding systems as well as the National Correct Coding Initiative (CCI) Edits Proactive Processes To Employ Provide an active coding education program Conduct coding quality audits HIM Management Team needs to stay current with national and local coding and billing issues Review the Office of the Inspector General s Work Plan every year Keep open communications with the Compliance Department Assure the coding team is involved with system wide preventive or proactive processes for coding and billing Copyright California Health Information Association, AHIMA affiliate 6

8 Active Coding Education Subscribe to AHA s ICD 9 CM/ICD 10 CM/PCS Coding Clinic Subscribe to AHA s HCPCS Coding Clinic Subscribe to AMA s CPT Assistant Support staff obtaining their coding professional continuing education units Provide Coding Staff with Coding Resources Disease processes reference sources If possible, on line reference library and portal site See an example of ACORN next slide Sample of An On line Resource: ACORN s Resources for you Copyright California Health Information Association, AHIMA affiliate 7

9 Sample of An On line Resource: ACORN s Coding FAQs Sample of An On line Resource: ACORN s Helpful Links Copyright California Health Information Association, AHIMA affiliate 8

10 Coding Quality Audits Quality audits should be performed regularly Audit focus should consider the OIG Work Plan target areas The target areas may not be services the facility provides; if they are, assess the facility s risk Review the facility s PEPPER Report and plan accordingly Is the facility within the acceptable range, under reporting, or in the red? Analyzethe NCD/LCDs Are any of these high volume and/or high dollar for your facilities? Is the organization receiving appropriate reimbursement for these services? Overview of the PEPPER Reports PEPPER provides provider specific Medicare data statistics for discharges/services vulnerable to improper payments PEPPER can support a hospital or facility s compliance efforts by identifying outlying risk areas. This data can help identify both potential overpayments, as well as, potential underpayments It s purpose is to provide comparative data reports to hospitals and to Medicare Administrative Contractors/Fiscal Intermediaries Copyright California Health Information Association, AHIMA affiliate 9

11 How HIM Can Stay Current with Compliance Issues Review the Office of the Inspector General s Work Plan every year Keep open communications with the Compliance Department Assure the coding team is involved with system wide preventive or proactive processes for coding and billing The OIG Office of the Inspector General Mission Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries History Since its 1976 establishment, OIG has been at the forefront of the Nation's efforts to fight waste, fraud and abuse in Medicare, Medicaid and more than 300 other Health Human Services (HHS) programs HHS OIG is the largest inspector general's office in the Federal Government, dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs. A majority of OIG's resources goes toward the oversight of Medicare and Medicaid programs that represent a significant part of the Federal budget and that affect this country's most vulnerable citizens. OIG's oversight extends to programs under other HHS institutions, including the Centers for Disease Control and Prevention, National Institutes of Health, and the Food and Drug Administration Copyright California Health Information Association, AHIMA affiliate 10

12 The OIG Work Plan The HHS Office of Inspector General (OIG) Work Plan for Fiscal Year 2014 provides brief descriptions of activities that OIG plans to initiate or continue with respect to HHS programs and operations in fiscal year The Work Plan describes the primary objectives and provides for each review its internal identification code, the year in which we expect one or more reports to be issued as a result of the review, and indicates whether the work was in progress at the start of the fiscal year or will be a new start during the year https://oig.hhs.gov/reports andpublications/workplan/index.asp#curret Communications with the Compliance Department Get to know your Compliance Department s Team Inquireif if you have: A coding specialist team A monitoring program for coding, billing, and reporting Any committees the HIM management team should serve on What resources or communications does the department publish Many now have portal sites Are there any areas around coding and reporting the HIM department can participate in or with Copyright California Health Information Association, AHIMA affiliate 11

13 System wide Proactive Processes Whenever possible assure the coding team is involved with system wide preventive or proactive processes for coding and billing Assure physician queries are compliant Monitor the text of physician queries develop templates Limit who can issue physician queries These are work processes that encourage and support compliant coding and billing An Example of a System wide Process Compliance Department s analysis of Current LCDs: Identified Total Knee Arthroplasty Replacements (TKA) were high volume and high h dollar Some hospitals had fewer payment denials than other hospitals in our system Risk Assessment performed and identified key controls and monitored points throughout the revenue cycle Key departments were invited to participate in the analysis process Compliance developed a tool kit that consisted of Workflow chart identifying the workflow and monitoring points within the workflow Pre operative Check off list that reflected the LCD s requirements for payment Developed work processes to monitor completion of the pre op check of list, billing steps depending on the status of the check off list, and reporting processes for reimbursement, denial, and/or bill for non payment rates Copyright California Health Information Association, AHIMA affiliate 12

14 Overview of the Departments and Their Roles in the TKA Payment Process Physician s office schedules surgery Hospital registration department notifies Pre Op Reviewer of scheduled surgery Pre Op reviewer requests patient s medical history and therapies on checkoff list. If documentation doesn t support surgery (based on LCD), a second level review is initiated. Physician contacted to discuss check off list results After surgery, coding receives discharge record and verifies pre op check off list completed. If missing, rerouted to reviewer to locate documents. If completed and meets, case is coded and sent to billing. If completed and did not meet, codes discharges and notifies billing Billing will bill discharges that met LCD as an inpatient. Discharges that didn t meet are billed as inpatient no payment Quarterly Billing and Compliance report to Chief Compliance Officer and Chief Financial Officer on reimbursement and denial rates for TKA Total Knee Arthroplasty Tool Kit Items Copyright California Health Information Association, AHIMA affiliate 13

15 Pre Op Check off List Risk Matrix for Total Knee Arthroplasty (TKA) Copyright California Health Information Association, AHIMA affiliate 14

16 Flowchart for TKA The professional coder s role in a compliance investigation or audit Copyright California Health Information Association, AHIMA affiliate 15

17 Compliance Investigation and/or Audit Unfortunately, all the best efforts may still leadto an external or internal investigation or audit It is very important that a Professional Coder is a participant of the investigation or audit The next slides will discuss the Professional Coder s role in an investigation/audit and why it is important to have them on the investigation team The Coder s Role in the Investigation Remain neutral at all times As a professional coder, and a compliance professional; your role is to gather the facts (data) Don t have opinions before you start to gather facts (data) Approach each investigation as if it is the first time you have encountered the issue Clearly understand the objective of the investigation Treat the allegation seriously, and confidentially Audit or review the data in question Copyright California Health Information Association, AHIMA affiliate 16

18 The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Work with the investigatory team so that everyone clearly understands the objective of the investigation and the audit Plan the audit or review: What is the Scope of the audit? Who or what is going to be reviewed (i.e. M.D., Hospital, Hospital department etc.) What is the universe of data to be reviewed? Timeline? Retrospective vs Prospective? Volume of data? Codes Sets? Where will the data come from? Clinical Systems (ehr) Billing Systems Claims Adjudication Systems Add on systems : i.e. MIDAS, Radiant, Arius, Smarttools etc. Data validation steps The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Plan the audit or review: What tools will be used for the audit? External tools, internal tools Where will the data be stored and who will have access to the data? Protected shared drive, portal or collaboration site, teammate etc. What methodology will be used to conduct the audit? What are the processes and/or procedures that will be used to measure the risk? Will the audit be statically valid or simply a probe audit? Affects next step decision making Whatare are the benchmarks (federal, state, payerguidelines or contractual obligations) that the data will be measured against? Abundance of material that provides coding and billing advice or guidelines what will you use to define and defend the issues reported? Who will be interviewed? Necessary to ascertain whether a coding error or an operational issue Copyright California Health Information Association, AHIMA affiliate 17

19 The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Plan the audit or review: Will the audit be conducted on site or off site? Important to ensure confidentiality of the audit process regardless of location What are the plans for routine meetings with the investigatory team? Absolutely essential to ensure audit scope, objectivity and accuracy What are the plans for communication to the leadership team? Important to keep them in the loop as the audit process progresses Timeline for completion of the audit? Can rely on industry accepted standards for audit completion Will there be a Quality Assurance Process? Always a good idea, helps to preserve the integrity of the work performed The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Execute the audit: Findings should be documented as brief statements with references: i.e. Documentation does not support E/M service coded/billed. Ref: AMA CPT Evaluation and Management Guidelines; CMS Guidelines for Evaluation and Management Coding 1994/1997 Findings should be recorded in a way that identifies trends in aberrant coding/billing practices Early audit findings that trend to an anticipated high error rate should be reported immediately to the Compliance Officer, and/or Investigator Errors should be tracked and reported both in accuracy and financial impact to the organization Reporting allowed services is just as important as reporting errors Copyright California Health Information Association, AHIMA affiliate 18

20 The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Execute the audit: Interviews: OK for the Professional Coder to conduct interviews with key members of coding/billing and operational staff Questions for the interviews should be preplanned, with some anticipation of outcome, and should be able to help explain audit results Important to work with Compliance Officer and/or Investigator Interviews must be documented; and accurately report what the interviewee reported Interviews should be documented in a manner that is clear to the reader what has been said Interview documentation should only reflect the facts of the interviews, not the opinion of the Professional Coder The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Report the audit findings: Professional coder can issue a report to the Compliance Officer or Investigator who then can incorporate into the final report The report: Should be fact based and include credibility determinations or conclusions Should demonstrate a Compliance Accuracy Rate and a Financial Impact Error Rate May include cause and effect conclusions based on operational interviews and observations May include conclusions based on coding regulations, guidelines and payer specific contractual obligations Copyright California Health Information Association, AHIMA affiliate 19

21 The Coder s Role as Auditor in the Investigation: Plan, Execute, Report, Corrective Action Corrective Action May or may not be necessary as part of the Professional Coder s role Should be determined ahead of time as part of the planning process whether this should be incorporated dinto the work performed dby the Professional Coder In Summary A Professional Coder is a key player in an organization s compliance program whether it is coding the chart, participating in a monitoring process of an NCD/LCD, or an audit or investigation Healthcare systems need to keep their coding staff current with the latest coding, reporting, and billing requirements It is important that HIM Managers and Coders understand their role in supporting hospitals staying compliant with ihcoding, billing, and reporting, as well as the total revenue and billing cycle for a hospital s services Copyright California Health Information Association, AHIMA affiliate 20

22 The Professional Coder s Role in the Investigation Questions? Bibliography Troklus & Warner Compliance 101. Second Edition. Health Care Compliance Association (2007). Glossary. AHIMA Code of Ethics cuments/ahima/bok2_ hcsp?ddocname= bok2_ Office of the Inspector General https://oig.hhs.gov/about oig/about us/index.asp Copyright California Health Information Association, AHIMA affiliate 21

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