HAAD Clinical Coding Steering Committee Meeting

Date/Time/Place: April 8, 2009; 10 am; HAAD Conference Room Presiding Chair: Ann L. Webster, RHIA, CCS Tawam Hospital Recorder: Ann L. Webster, Tawam Hospital Voting Members Present: Voting Members Absent: Apologies: Guests: HAAD Clinical Coding Steering Committee Meeting Jameel Ahmed, Western Region; June Beaumont, Al Ain Hospital; Malda Ellahham, Daman; Michelea Peech, Al Noor Hospital, Al Ain. Dr. Mohammad Ansari, Daman Dr. Sameer Khan, NAS Binu Paul, Mafraq Hospital; V. Sunil, Al Rahba Hospital; Pam Gyles, Zayed Military Hospital. Item No Matters Discussed & Decision Taken Person Responsible For Action Target Date 1.0 Call to order The meeting was called to order at 10:10 am. Chair 2.0 Apologies and Guests Apologies from: Dr. Sameer Khan. 3.0 Review/Revision of Previous Minutes Minutes of February and March 2009 were being posted on the HAAD website in PDF format. Minutes of March 2009 were unable to be posted on the Wikki as there was a security problem. Jameel will follow this up and get the minutes posted as soon as possible. 4.0 Education Sub-committee June presented the minutes from her first Education Subcommittee meeting. Her members are Selvakumar from Corniche, Binu Paul from Mafraq, Leopoldo from Tawam, and Malda Ellahham from Daman. She was asked to forward her Terms of Reference for the Committee to all of the CCSC members for consideration and discussion at the next meeting. Jameel April 2009 June April 2009

There was discussion regarding receiving questions from the coding community and the flow will be that the Education Committee receives the question, the members research the answer, the answers are documented with references and sent to the CCSC members prior to the next meeting, the CCSC members agree on the answers and then they are published on the Wikki site. It was stressed that getting the consensus of the CCSC members was essential before anything was published to the coding community. The next Continuing Coding Education session will be held at SKMC on April 22 nd. 5.0 Audit and Arbitration Sub-Committee Jameel reported that he has not had a meeting yet for his committee as he was waiting for information from the methodology document from Perot for the coding audit. He was asked to prepare his terms of reference for the May meeting and have his members selected. Michelea volunteered to join the sub-committee and so she is the first member. It is essential that there be a payer member on this sub-committee as well. Jameel April 2009 6.0 Coder Credential Document June has prepared the document regarding the credentialing of coders and will send this to Jameel to get it posted on the Wikki site. She also clarified for the minutes the following credentials: AHIMA Credentials: CCS; CCA; CCS-P AAPC Credentials: CPC 7.0 Coding Error Definition Clarification Ann clarified for the minutes that the E-Code coding error, which was moved to a major error on the Perot audit, will be moved back to a minor error, as per the CCSC previous decision. This change will be made in the coding audit methodology document. 8.0 Confidentiality Policy Deferred. Malda offered to send the HIPPA information to Ann for inclusion/consideration in the confidentiality document. June Jameel Malda Ann April 2009 April 2009 9.0 Wikki Site Maintenance There have not been any meetings yet by Dr. Khan regarding the Wikki site maintenance so Ann will contact him to see if he still wants to do this. If not, Michelea and Pam offered to take care of it. 10.0 Coder Training Michelea and Oasis Hospital Due to some misunderstanding, the Oasis Hospital will not be offering the coding training to physicians now, but Ann April 2009 Michelea April 2009

will offer training for Coders at a cost. This will be communicated to the coding community when it is known. Michelea is planning to provide her coding training starting in early May. This will be a basic coding training course for any interested parties, offered for free and hosted by HAAD at the HAAD auditorium. Details will be sent out as soon as they are available. 11.0 Coding Audit Update Ann reported that the audit methodology was just received two days earlier from Perot. She will meet with Philipp Vetter to review the document and then it will be presented to the CCSC. There may need to be a separate meeting for that as it will require some lengthy discussion. After the document is reviewed and accepted by the CCSC, there will need to be further meetings with the community to discuss the process for the audit and certification. 12.0 Proposal for Coding Consultations for Non-Physician Clinicians After lengthy discussion, the following proposal was adopted unanimously: Non-physician clinician to use CPT E&M codes (99201 99215) for their outpatient clinic visit when they are seeing and treating the patient as an independent clinician for that visit. As an interim solution until facilities are certified to use the CPT E&M code levels for billing, they can use three service codes for three levels of service by the non-physician clinicians. The specific descriptions for the above three service code levels will be given to Ann by Malda as they have already been developed. The E&M codes cover/include all non-codeable procedures provided by all clinicians such as dressing changes, cast removals, suture removals, wound care, etc. E&M codes also include the consultation and assessment part of the visit for the non-physician clinicians. This would include Nurses, Speech Therapists, Dieticians, PT/OT, Respiratory Therapists, Audiologists, etc. (We would expect the prices for these non-physician clinicians to be different from physician prices; however pricing is not in the scope of the CCSC responsibilities.) This rule would only apply when the patient is scheduled and registered as a visit with that particular non-physician clinician. This is not for cases where the non-physician clinician procedure is part of a physician clinic visit. Ann April 2009

As this proposal requires service codes to be assigned from HAAD, Ann will take this proposal to Dr. Finn Goldner for discussion and action. 13.0 Proposal for Coding Home Health Visits After lengthy discussion the following proposal was adopted unanimously: To create an additional field on the claim form for Place of Service in order to use the CPT place of service codes to designate special situations such as home care or prison. This field to be mandatory for all claims. Ann April 2009 Ann March 2009 Additionally to use the E&M codes (99341 99350) for both physician and non-physician clinicians treating patients in the home. In the interim, until the facility is certified to use the levels of E&M codes for billing, to use the service codes for non-physicians as proposed in the previous proposal in #12. In using the place of service codes, any procedure performed in the home can be coded using the correct CPT code. This gives unlimited flexibility in correctly identifying those procedures performed in the home or elsewhere. The E&M codes cover/include all non-codeable procedures provided by all clinicians such as dressing changes, cast removals, suture removals, wound care, etc. E&M codes also include the consultation and assessment part of the visit for the both the physician and non-physician clinicians. Only one clinician can use the E&M code in each home visit, if they go as a team. The non-physician clinicians would include Nurses, Speech Therapists, Dieticians, PT/OT, Respiratory Therapists, etc. (We would expect the prices for these non-physician clinicians to be different from physician prices; however pricing is not in the scope of the CCSC responsibilities.) 14.0 Tooth Number on Claim Proposal The proposal was adopted unanimously: Add the tooth number to the observation field on the claims for all patients with dental procedures requiring Canadian Dental Association (CDA) codes. Malda April 2009 Malda will provide the format and description for the tooth number.

If there is more than one tooth involved, then all tooth numbers will be listed. If the procedure was not on a tooth but on the gum or mouth structure, then the tooth number or numbers closest to the procedure performed, are to be listed. 15.0 Delivery Codes Jameel raised the issue of delivery codes in pre-authorizations with Daman. He had received instructions through email regarding using the delivery code without postpartum care on the claim. Malda April 2009 Malda clarified that this was an internal mis-understanding at Daman and that she would take steps to correct this coding conflict. The correct codes for deliveries if post partum care is given is 59410 for vaginal delivery and 59515 if C-section. 16.0 Outpatient Follow Up Visit Ann had contacted HAAD for clarification on the rule regarding not charging for a follow up visit within 7 days for outpatients. She had a discussion and email from Dr. Shereefa Afreen at HAAD explaining that this was according to Law No. (23) of 2005 and the Executive Regulations Regarding the Health Insurance Scheme for the Emirate of Abu Dhabi. This can be found on the HAAD website and the page referenced was page #38. If anyone is interested in the link to this document please contact Ann. In addition, Malda mentioned that this rule was part of the Daman agreement with the healthcare facilities. Ann asked if she could provide this in writing to the committee as well. The law is not specific to the follow up visit being for the same diagnosis, however in conversation with Dr. Shereefa, it was stated that this was understood. On the other hand, when Malda explained from the Daman perspective, the visit within seven days did not have to be for the same diagnosis. If a patient comes back to the doctor within seven days for a totally unrelated diagnosis, then that can be considered to be an independent visit, not a follow up visit. If, however, the condition or diagnosis discovered on the visit within 7 days should have been detected on the first visit, then that would be a follow up visit and not chargeable. The guideline then is that it is up to the care provider to determine if this is a follow up visit based on whether the condition is new or a follow up of the condition on the previous visit or something that was missed on the previous visit. All billed outpatient clinic visits within 7 days will be scrutinized to determine if they should have been considered a follow up visit and therefore not charged for. Malda May 2009 17.0 ICD9CM Code Descriptions on HAAD Website Jameel had discovered a few E codes on the HAAD website that were not true codes for ICD9CM version 2008. This is a concern as this is the legal reference for ICD9CM codes. Jameel will work with Elleanor Baker in Dr. Philipp Vetter s office to get this resolved. There have been email discussions with 3M to provide long Jameel May 2009

descriptions of the codes; however this would come with a price. Jameel will discuss this with Dr. Vetter and follow up at the next meeting. 18.0 Diagnoses for Prescriptions Ann clarified the new regulation requiring diagnosis codes on prescriptions. The diagnosis code(s) must justify the use of the prescribed medication. If there are multiple drugs prescribed for one diagnosis, then only that diagnosis must be coded. If there are multiple drugs prescribed for multiple diagnoses, then all diagnoses must be coded on the prescription. It is the responsibility of the dispensing pharmacy to ensure that there is a correlation between the drug prescribed and the diagnosis on the prescription. Concern was expressed regarding the ability of pharmacies being able to understand the codes that were on the prescriptions. 19.0 Definition of Occupational Injury Ann asked HAAD for clarification of the definition of work place for an occupational injury. According to the labor law, Article 13 Accidents at work: What is considered as a work accident: A work accident is an accident which has been suffered by an employee at his place of work or while traveling to or from his place of work. 20.0 Coding Communications Communications regarding coding rules have come from Daman in the last couple of weeks and were discussed by the committee: 99212 to be used for the follow up outpatient visit T1031 to be used for home nursing care 97039 to be used for home physiotherapy Ann clarified that the only body that can change the meaning of an established code is the Data Standards Panel, as per Dr. Philipp Vetter at HAAD. Even the CCSC does not have the authority to change the meaning of the code. It was the consensus of the committee to remind the healthcare community that all coding clarifications, rules and interpretations should come through the CCSC. This will be communicated to the appropriate parties at HAAD by Ann and to Daman by Malda and to NAS by Dr. Khan. 21.0 Assignments for Next Meeting As time ran out, members were asked to prepare to discuss the unlisted procedures (CPT codes) process for coding and claims for the next meeting. In addition, the Committee will review and discuss the Terms of Reference for the two sub-committees. Ann Malda Dr. Khan April 2009

22.0 Next Meeting May 13, 10 am at HAAD in 1 st floor conference room Members 23.0 Adjournment The meeting adjourned at 12 noon. Major Decisions and Actions, Final and Pending for Clinical Coding Steering Committee 2009 001 Add CCSC minutes to HAAD website. Jameel Ahmed April 2009 002 Update Coding Manual and post on HAAD website. Ann Webster April 2009 003 Establish testing center for coding credentials with American Health Information Management Association in Abu Dhabi. Site identified as Prometrics in Dubai. They have agreement with AHIMA to do the testing. June will prepare document with instructions for coders interested in taking the test as well as which credential is recommended by CCSC. Document has been prepared and June will send to Jameel to add to the Wikki site. 004 Dental Coding - Dental Coding regulation changed to read When dental procedures are performed outside of a recognized dental center or dental clinic, i.e. Maxillofacial Clinic, Inpatient or Day patient surgical episodes; the Canadian Dental Association procedure codes can be used if and only if there is not a specific CPT code for the dental procedure. For June Beaumont April 2009

avoidance of doubt: CPT code 41899 (unlisted dental procedure) is not a specific CPT code and is not acceptable in these circumstances. 005 Confidentiality Policy for HAAD Data Standards Panel Members March 2009 006 Coding error defined by Committee members. Will be refined and presented to auditors. Ann Webster March 2009 007 DOA If facility attempts to resuscitate a Dead On Arrival patient then it is possible to submit a claim for that encounter. All DOAs must be reported to HAAD in standard data submission reporting process. 008 Mixed claim with covered and non-covered services in same encounter. Ann to follow up with Data Standards Panel. Ann Webster April 2009 009 Statement for Pre-authorization process: In the pre-authorization process, if the actual procedure performed is a logical regression or progression of the approved procedure(s), for medical necessity reasons only, no further application for approval is needed, after the fact. Approved and sent out from Dr. Finn at HAAD. 010 Modifiers to CPT codes 77 and 76. There seems to be a difference of opinion on the definitions of these modifiers and how they are being used by the payer. The definitions per the CPT book are: 76- Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. 77 Repeat Procedure by Another Physician The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service. Michelea Peech February 2009 Pending discussion in May regarding all modifiers. Malda Ellahham, June Beaumont, Michelea Peech

This will be further researched by Michelea and communicated to CCSC members. 011 Reorganization of CCSC: Voting members to include 3 payer and 3 provider members: 2 SEHA 1 Private Hospitals 2 Daman 1 NAS Two sub-committees: Education Sub-committee Audit/Arbitration Sub-committee Voting for representation on February 24 th at coding seminar at HAAD. 012 Coding Audit Coding audit for all healthcare organizations by sub-contracted company from HAAD Perot to audit ICD9CM diagnosis coding, CPT4 procedure coding as well as Evaluation and Management Coding (E&M). Certify E&M coding as accurate then healthcare facility can bill Started March 2009 Pilot Audit March 2009 using E&M codes. 013 Prepare health information confidentiality policy for Data Standards Panel Ann Webster - In process April 2009 014 Statement for diagnosis coding for claims: The diagnosis approved for admission and the subsequent complication diagnoses approved for extended length of stay for inpatients are to be considered working diagnoses and will most often be different from the final or discharge diagnoses. As long as the discharge diagnoses have a logical correlation to the approved diagnoses, claims cannot be denied because the codes are different than those that were approved for the inpatient stay. 015 Clarification regarding claims/billing from Dr. Goldner at HAAD: HAAD will develop rules for validity of prescriptions (market practice until then should Pending distribution from Dr. Finn at HAAD, February 2009

be extended to 30 days, i.e. pharmacy, lab, radiology, other tests). Future orders will be handled differently based on the timing of the order, i.e. patient to have echocardiogram in three months then return to clinic. Preauthorized tests have specific validity based on the dates of the authorization. Podiatrist s outpatient clinic visits will be billed as GP for service code if medically necessary, providing their Podiatry license number as issued by HAAD licensing authority. Case Managers cannot sign for extensions of inpatient visits unless specifically licensed as case managers through the HAAD licensing authority. (Currently no such licensing). Hospitals can charge for ambulance services using HCPCS codes for covered patients, as per their agreements with Daman. 016 Endorsement of coding education and training companies The CCSC will not endorse companies however we can/will pass on training opportunity information to coding community and post on Wikki site. 017 Consumer document for healthcare facilities seeking companies to provide coding education and training will be developed by Michelea Peech. Document to include tips for consumers regarding choosing the right company for the job. 018 Basic coder training for diagnoses and procedures offered by Michelea Peech, sponsored by HAAD. Michelea has scheduled training sessions with HAAD. Will be published on Wikki and will be marketed to all healthcare facilities in Abu Dhabi. Will begin in April 2009 Michelea Peech, March 2009 Michelea Peech, April 2009 019 Presentation at HAAD by Ingenix on Clinical Coding A Way Forward for Abu Dhabi. January 29, 2009 020 List of Vendors for Wikki site. All Members May 2009 021 June Beaumont is the new sub-committee Chair for the Education Sub-committee. She will gather her committee and prepare their Terms of Reference and education schedule for the year. 022 Jameel Ahmed is the new sub-committee Chair for the Coding Audit and Arbitration Subcommittee. He will solicit members and prepare their Terms of Reference for the next meeting. 023 The Committee agreed to recommend to healthcare facilities the following credentials for coders: CCS Certified Coding Specialist, (experienced coders) for all coders in tertiary care hospitals and at least one in all other hospitals; at least one at insurance companies in audit department May 2009 May 2009

CCA Certified Coding Associate, (entry level coders), for outpatient coding or coders at small hospitals CCS-P Certified Coding Specialist Physician Based (experienced coders in physician offices), for outpatient clinics or individual physician clinics AAPC American Academy of Professional Coders (coders in physician practices and outpatient settings), specific for outpatients, physicians offices and emergency departments. 024 Definition of Coding Error by CCSC for coding audit. Needs further modification regarding E codes. Major Moderate Minor Incorrect code number, diagnosis or procedure Missing principal diagnosis Diagnosis coded without documentation Missing procedure code Procedure coded without documentation Error of specificity in procedure code Missing delivery outcome V code Incorrect selection of principal diagnosis Error of specificity in diagnosis code (i.e. pneumonia instead of bacterial pneumonia) Missing additional diagnosis Missing V code as secondary diagnosis (i.e. history of cancer) Missing E code 025 Coding Audit Methodology Methodology document received from Perot. Ann to meet with Dr. Philipp Vetter on document and bring to next CCSC meeting for discussion. Amended April 2009 May 2009

026 Proposal for Coding Consultations for Non-Physician Clinicians: Non-physician clinician to use CPT E&M codes (99201 99215) for their outpatient clinic visit when they are seeing and treating the patient as an independent clinician for that visit. April 2009 Adopted unanimously by CCSC. As an interim solution until facilities are certified to use the CPT E&M code levels for billing, they can use three service codes for three levels of service by the non-physician clinicians. The E&M codes cover/include all non-codeable procedures provided by all clinicians such as dressing changes, cast removals, suture removals, wound care, etc. E&M codes also include the consultation and assessment part of the visit for the non-physician clinicians. This would include Nurses, Speech Therapists, Dieticians, PT/OT, Respiratory Therapists, Audiologists, etc. (We would expect the prices for these non-physician clinicians to be different from physician prices; however pricing is not in the scope of the CCSC responsibilities.) This rule would only apply when the patient is scheduled and registered as a visit with that particular non-physician clinician. This is not for cases where the non-physician clinician procedure is part of a physician clinic visit. 027 Proposal for Coding Home Health Visits: To create an additional field on the claim form for Place of Service in order to use the CPT place of service codes to designate special situations such as home care or prison. This field to be mandatory for all claims. April 2009 Adopted unanimously Additionally to use the E&M codes (99341 99350) for both physician and non-physician clinicians treating patients in the home. In the interim, until the facility is certified to use the levels of E&M codes for billing, to use the service codes for non-physicians as proposed in the previous proposal in #12. In using the place of service codes, any procedure performed in the home can be coded using the correct CPT code. This gives unlimited flexibility in correctly identifying those procedures performed in the

home or elsewhere. The E&M codes cover/include all non-codeable procedures provided by all clinicians such as dressing changes, cast removals, suture removals, wound care, etc. E&M codes also include the consultation and assessment part of the visit for the both the physician and non-physician clinicians. Only one clinician can use the E&M code in each home visit, if they go as a team. The non-physician clinicians would include Nurses, Speech Therapists, Dieticians, PT/OT, Respiratory Therapists, etc. (We would expect the prices for these non-physician clinicians to be different from physician prices; however pricing is not in the scope of the CCSC responsibilities.) 028 Tooth Number on Claim Proposal: Add the tooth number to the observation field on the claims for all patients with dental procedures requiring Canadian Dental Association (CDA) codes. April 2009 Adopted unanimously Malda will provide the format and description for the tooth number. If there is more than one tooth involved, then all tooth numbers will be listed. If the procedure was not on a tooth but on the gum or mouth structure, then the tooth number or numbers closest to the procedure performed, are to be listed. 029 Clarification of follow up visit for outpatients: Follow Up outpatient visits within 7 days are not to be charged for. Follow up visits are defined as the same diagnosis with the same sub-specialty and/or diagnoses that existed at the time of the original visit that should have been discovered on that visit. 030 Diagnoses for Prescriptions: There must be a diagnosis code to justify all drugs ordered on a prescription and it is the responsibility of the dispensing pharmacist to ensure this correlation. 031 Definition of Occupational Injury: Workplace injury is defined by Labor Law, Article 13 as an accident at work. An accident at work is defined as an accident which has been suffered by an employee at his place of work or while traveling to or from his place of work. 032 All coding rules, interpretations, clarifications are to come through the CCSC for official determination and publication. This includes the providers, payers and HAAD.

Date/Time/Place: March 11, 2009; 10 am; HAAD Conference Room Presiding Chair: Ann L. Webster, RHIA, CCS Tawam Hospital Recorder: Ann L. Webster, Tawam Hospital Voting Members Present: Apologies: Guests: HAAD Clinical Coding Steering Committee Meeting Jameel Ahmed, Western Region; June Beaumont, Al Ain Hospital; Dr. Mohammad Ansari, Daman; Dr. Riham for Malda Ellahham, Daman; Dr. Sameer Khan, NAS. Michelea Peech, Al Noor Hospital, Al Ain; Malda Ellahham Nestor Sibayan, Tawam Hospital; Joan Grey, HAAD; Sameera Al Hashemi, SKMC; Binu Paul, Mafraq Hospital; Rising, Al Rahba Hospital; Carol Bourland, Perot. Item No Matters Discussed & Decision Taken Person Responsible For Action Target Date 1.0 Call to order Chair The meeting was called to order at 10:15 am. 2.0 Apologies and Guests Apologies from: Michelea and Malda. Members introduced themselves to the guest from Perot, Carol Bourland, who is in charge of the coders performing the coding audit. 3.0 Review/Revision of Previous Minutes Minutes of February s meeting are not yet posted on the HAAD website as they have to be converted to Excel format. Jameel will convert them. They have been posted on the Wikki website. Jameel March 2009

4.0 Sub-committee Chairmen Ann introduced the Sub-committee chairmen, June Beaumont for the Education Sub-committee and Jameel Ahmed for the Audit and Arbitration Sub-committee. The Sub-committee Chairs were asked to find members for their committees and to prepare their scope of work for discussion at the next CCSC meeting. June and Jameel April 2009 5.0 Update of Coding Manual and Proposal to Update Code Sets Deferred Ann April 2009 6.0 Coding Seminars March 19 th Corniche April 22 nd SKMC Further coding seminars will be coordinated by the Education Sub-committee. 7.0 AHIMA Coder Credentialing June reported on her findings regarding the AHIMA credentialing. There is a Prometrics center in Dubai and Prometrics has a contract with AHIMA to serve as a test site. The coder needs to go to the AHIMA website and fill out an application then contact Prometrics for the testing. June offered to put together the process in writing, so that we can distribute this to the coding community and put it on the Wikki site for reference. There is an issue of timing for the test that will determine which system the coder will be tested on, codes from 2008 or 2009. June will explain the details of that in her document. In addition she offered to list the recommended materials for the coder to have and reference before taking the exam, as well as what is acceptable to take to the exam itself, i.e. coding books. The Committee agreed to recommend to healthcare facilities the following credentials for coders: CCS Certified Coding Specialist, (experienced coders) for all coders in tertiary care hospitals and at least one in all other hospitals; at least one at insurance companies in audit department CCA Certified Coding Associate, (entry level coders), for outpatient coding or coders at small hospitals CCS-P Certified Coding Specialist Physician Based (experienced coders in physician offices), for outpatient clinics or individual physician clinics AAPC American Academy of Professional Coders (coders in physician practices and outpatient settings), specific for outpatients, physicians offices and emergency departments. June April 2009 June has prepared a document regarding the levels of coding credentials, which she will share with the CCSC and June April 2009

post on the Wikki site before the next meeting. 8.0 What is a coding error? The following was ranked after the last meeting and with consultation from Dr. Vetter. The biggest change was moving the E-code to the major category. Major Moderate Minor Incorrect code number, diagnosis or procedure Missing principal diagnosis Diagnosis coded without documentation Missing procedure code Procedure coded without documentation Error of specificity in procedure code Missing E code Missing delivery outcome V code Incorrect selection of principal diagnosis Error of specificity in diagnosis code (i.e. pneumonia instead of bacterial pneumonia) Missing additional diagnosis Missing V code as secondary diagnosis (i.e. history of cancer) The Committee discussed the ranking of the E-code and had concerns in placing it so high in the ranking and the reason of it being linked to work place injuries was not justified as it does not identify such. Ann will discuss this further with Dr. Vetter and get back to the Committee on this point. Ann April 2009 9.0 Confidentiality Policy Deferred Ann April

2009 10.0 Wikki Site Maintenance Dr. Khan reported that he will meet with the volunteers who agreed to assist him in updating the Wikki site, before the next meeting. He also mentioned that he plans to have different boxes/buttons on the website that lead to different subjects such as credentialing, selection of coding company for education/coding/audit, coding seminars and queries. He will report at the next meeting in April. 11.0 Oasis Hospital Sponsored Training and Coding Training by Michelea Peach Ann reported that Michelea has been working with Luis Perfetti at Oasis Hospital on the training to be offered at HAAD for physicians regarding coding. An update will be given at the next meeting. Michelea is also now scheduling her own training which will be offered for free at HAAD around the end of April for coders, which can include physicians as well. She has been coordinating with Elleanor in Dr. Vetter s office, to get the auditorium booked and set up the training sponsorship. Michelea will report at the next meeting. 12.0 Coding Audit Discussion Ann introduced Carol Bourland again as the Coding Audit coordinator from Perot for the pilot project. The Committee members discussed the audit process and came up with the following recommendations: o The audit must look at a cross section of the outpatient clinics, not by physician but by clinic. o In order to randomly select clinic visits to audit, the facility would produce a list of clinic visits for a period of time (30 days) from which the auditor would select randomly cases to audit. o It is important to select more records than are needed in case the specific record is not available on the day of the audit; i.e. for 50 records select 100 on the list. o The facility must produce a document or report of which codes were submitted on the claim, for the auditors to compare to the documentation in the medical record. (cases do not need to have been paid, just submitted) o The audit will only be of the diagnoses and procedures that are normally coded by a coder. This means generally the procedures performed in the clinics, in the operating room, in the emergency department and specialty radiology procedures, invasive procedures performed in specialty areas such as endoscopy and interventional radiology. They will not audit for drug codes, lab procedure codes or routine X-ray codes or diagnosis codes on prescriptions. o The auditor will produce a report for the facility that is comprehensive with details about the coding results Dr. Sameer Khan Michelea April 2009 April 2009

o o including the medical record numbers and specific coding errors. There will be a more general report for the CCSC that has the overall score and the process documentation, including a flow chart of the process. The facility can choose to ask for certification after the audit, in which case this report will be sent to the CCSC. If the facility chooses not to ask for certification at this time, the report will not be forwarded to the CCSC. The auditor will interview a physician, a coder, leadership for coding and someone from Finance in order to document the process of the coding from initial code to getting the code on the claim. This will be part of the certification scoring for a passing grade. Details regarding how the certification will take place still need to be ironed out. Ideally there should be a threshold where the facility needs to meet to pass and a higher threshold where the facility will not require a complete re-certification for another 2 years for example. A proposal regarding these details will be prepared by Ann, with the assistance of the Perot team, and will be brought to the next meeting for comments and revision. Ann April 2009 13.0 Stamp for CCSC with Logo Deferred Ann March 2009 14.0 Other Business o Dr. Riham brought up the issue of Home Care visit coding and the request to add service codes for different Home Care packages. Ann asked that this be put in writing as a proposal for the next meeting. June also offered to find information on how to do Home Care coding from what is used in the US. This will be put on the agenda for the next meeting, once a proposal is provided by Dr. Riham. Dr. Riham April 2009 19.0 Next Meeting April 8 th, 10 am at HAAD in 1 st floor conference room Members 20.0 Adjournment The meeting adjourned at 12 noon.

Major Decisions and Actions, Final and Pending for Clinical Coding Steering Committee 2009 001 Add CCSC minutes to HAAD website. Jameel Ahmed February 2009 002 Update Coding Manual and post on HAAD website. Ann Webster April 2009 003 Establish testing center for coding credentials with American Health Information Management Association in Abu Dhabi. Site identified as Prometrics in Dubai. They have agreement with AHIMA to do the testing. June will prepare document with instructions for coders interested in taking the test as well as which credential is recommended by CCSC. June Beaumont April 2009 Document has been prepared and June will distribute to CCSC and put on Wikki site. 004 Dental Coding - Dental Coding regulation changed to read When dental procedures are performed outside of a recognized dental center or dental clinic, i.e. Maxillofacial Clinic, Inpatient or Day patient surgical episodes; the Canadian Dental Association procedure codes can be used if and only if there is not a specific CPT code for the dental procedure. For avoidance of doubt: CPT code 41899 (unlisted dental procedure) is not a specific CPT code and is not acceptable in these circumstances. 005 Confidentiality Policy for HAAD Data Standards Panel Members March 2009 006 Coding error defined by Committee members. Will be refined and presented to auditors. Ann Webster March 2009 007 DOA If facility attempts to resuscitate a Dead On Arrival patient then it is possible to submit a claim for that encounter. All DOAs must be reported to HAAD in standard data submission reporting process. 008 Mixed claim with covered and non-covered services in same encounter. Ann to follow up with Ann Webster April 2009

Data Standards Panel. 009 Statement for Pre-authorization process: In the pre-authorization process, if the actual procedure performed is a logical regression or progression of the approved procedure(s), for medical necessity reasons only, no further application for approval is needed, after the fact. Approved and sent out from Dr. Finn at HAAD. 010 Modifiers to CPT codes 77 and 76. There seems to be a difference of opinion on the definitions of these modifiers and how they are being used by the payer. The definitions per the CPT book are: 76- Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. 77 Repeat Procedure by Another Physician The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service. This will be further researched by Michelea and communicated to CCSC members. 011 Reorganization of CCSC: Voting members to include 3 payer and 3 provider members: 2 SEHA 1 Private Hospitals 2 Daman 1 NAS Two sub-committees: Education Sub-committee Michelea Peech February 2009 Pending discussion in April regarding all modifiers. Malda Ellahham, June Beaumont, Michelea Peech Voting for representation on February 24 th at coding seminar at HAAD.

Audit/Arbitration Sub-committee 012 Coding Audit Coding audit for all healthcare organizations by sub-contracted company from HAAD Perot Started March 2009 to audit ICD9CM diagnosis coding, CPT4 procedure coding as well as Evaluation and Management Coding (E&M). Certify E&M coding as accurate then healthcare facility can bill using E&M codes. 013 Prepare health information confidentiality policy for Data Standards Panel Ann Webster - In process April 2009 014 Statement for diagnosis coding for claims: The diagnosis approved for admission and the subsequent complication diagnoses approved for extended length of stay for inpatients are to be considered working diagnoses and will most often be different from the final or discharge diagnoses. As long as the discharge diagnoses have a logical correlation to the approved diagnoses, claims cannot be denied because the codes are different than those that were approved for the inpatient stay. 015 Clarification regarding claims/billing from Dr. Goldner at HAAD: HAAD will develop rules for validity of prescriptions (market practice until then should be extended to 30 days, i.e. pharmacy, lab, radiology, other tests). Future orders will be handled differently based on the timing of the order, i.e. patient to have echocardiogram in three months then return to clinic. Preauthorized tests have specific validity based on the dates of the authorization. Podiatrist s outpatient clinic visits will be billed as GP for service code if medically necessary, providing their Podiatry license number as issued by HAAD licensing authority. Case Managers cannot sign for extensions of inpatient visits unless specifically licensed as case managers through the HAAD licensing authority. (Currently no such licensing). Hospitals can charge for ambulance services using HCPCS codes for covered patients, as per their agreements with Daman. Pending distribution from Dr. Finn at HAAD, February 2009 Complete 016 Endorsement of coding education and training companies The CCSC will not endorse Complete

companies however we can/will pass on training opportunity information to coding community and post on Wikki site. 017 Consumer document for healthcare facilities seeking companies to provide coding education and training will be developed by Michelea Peech. Document to include tips for consumers regarding choosing the right company for the job. 018 Basic coder training for diagnoses and procedures offered by Michelea Peech, sponsored by HAAD. Michelea has scheduled training sessions with HAAD. Will be published on Wikki and will be marketed to all healthcare facilities in Abu Dhabi. Will begin in April 2009 Michelea Peech, March 2009 Michelea Peech, April 2009 019 Presentation at HAAD by Ingenix on Clinical Coding A Way Forward for Abu Dhabi. January 29, 2009 Complete 020 List of Vendors for Wikki site. All Members April 2009 021 June Beaumont is the new sub-committee Chair for the Education Sub-committee. She will gather her committee and prepare their Terms of Reference and education schedule for the year. 022 Jameel Ahmed is the new sub-committee Chair for the Coding Audit and Arbitration Subcommittee. He will solicit members and prepare their Terms of Reference for the next meeting. 023 The Committee agreed to recommend to healthcare facilities the following credentials for coders: CCS Certified Coding Specialist, (experienced coders) for all coders in tertiary care hospitals and at least one in all other hospitals; at least one at insurance companies in audit department CCA Certified Coding Associate, (entry level coders), for outpatient coding or coders at small hospitals CCS-P Certified Coding Specialist Physician Based (experienced coders in physician offices), for outpatient clinics or individual physician clinics AAPC American Academy of Professional Coders (coders in physician practices and outpatient settings), specific for outpatients, physicians offices and emergency departments. April 2009 April 2009 024 Definition of Coding Error by CCSC for coding audit. Needs further modification regarding E codes. April 2009 Major Incorrect code number, diagnosis or procedure

Moderate Minor Missing principal diagnosis Diagnosis coded without documentation Missing procedure code Procedure coded without documentation Error of specificity in procedure code Missing E code Missing delivery outcome V code Incorrect selection of principal diagnosis Error of specificity in diagnosis code (i.e. pneumonia instead of bacterial pneumonia) Missing additional diagnosis Missing V code as secondary diagnosis (i.e. history of cancer)

HAAD Clinical Coding Steering Committee Meeting Date/Time/Place: February 11, 2009; 10 am; Corniche Hospital Library Conference Room Presiding Chair: Ann L. Webster, RHIA, CCS Tawam Hospital Co-Chair: Sameera Al Hashemi, SKMC Recorder: Ann L. Webster, Tawam Hospital Present: Nestor Sibayan, Tawam Hospital; Jameel Ahmed, Western Region; Velikakathu T. Sunil, Al Rahba Hospital; Joan Grey, HAAD; Michelea Peech, Al Noor Hospital, Al Ain; Selvakumar S, Corniche Hospital; Malda Ellahham and Anis Dohadwalla, Daman; June Beaumont, Al Ain Hospital; Dr.Bijin Samuel, NAS. Apologies: Dr. Sameer Khan, NAS; Binu Paul, Mafraq Hospital; Pam Gyles, Zayed Military Hospital; Mitchell Jesson, Tawam Hospital. Item No Matters Discussed & Decision Taken Person Responsible For Action Target Date 1.0 Call to order Chair The meeting was called to order at 10:15 am. 2.0 Apologies and Guests Apologies from: Dr. Khan, Binu, Pam and Mitchell. Members introduced themselves including Dr. Bijin, who was representing Dr. Khan from NAS and Malda and Anis from Daman who were at their first meeting. 3.0 Review/Revision of Previous Minutes Minutes of January 14 th meeting were posted on HAAD website as well as the Wikki site. There was an error in the date January 2008 instead of January 2009. Ann will ask for this to be corrected on the websites. Ann January 2009 4.0 Reorganization of CCSC Ann announced the re-organization of the CCSC voting members to include 3 provider members and 3 payer members, plus herself as Chair. The provider members will be elected at the next Coding Seminar, 2 from SEHA hospitals and 1 from Private hospitals. The payer members will be 2 from Daman and 1 from NAS. Ann February 2009

Quorum for the CCSC will be three members plus the Chair. All other attendees are encouraged to continue to attend the meetings and participate in discussions as previously. When voting occurs, only voting members will be allowed to vote. At the next coding seminar at HAAD on February 24 th, two SEHA representatives will be elected and one private hospital representative will be elected. Ann will ask for those interested in running for these positions to nominate themselves at the seminar. The SEHA coders present at the meeting will vote for their two representatives. The private hospital coders at the meeting will vote for their private hospital representative. There will also be only two sub-committees from now on. One for Education and one for Audit and Arbitration. Two of the voting members will serve as chairs of these sub-committees. Once the Chairs for these Subcommittees have been identified, interested coders in the community can volunteer to serve on one of these subcommittees. 5.0 Update of Coding Manual and Proposal to Update Code Sets Deferred Ann March 2009 6.0 Coding Seminars February 24 HAAD with Dr. Philipp and Ann presenting March Corniche April SKMC Further coding seminars will be coordinated by the Education Sub-committee. 7.0 AHIMA Coder Credentialing Education Subcommittee March 2009 June reported on her findings regarding the AHIMA credentialing. There is a Prometrics center in Dubai and Prometrics has a contract with AHIMA to serve as a test site. The coder needs to go to the AHIMA website and fill out an application then contact Prometrics for the testing. June offered to put together the process in writing, so that we can distribute this to the coding community and put it on the Wikki site for reference. There is an issue of timing for the test that will determine which system the coder will be tested on, codes from 2008 or 2009. June will explain the details of that in her document. In addition she offered to list the recommended materials for the coder to have and reference before taking the exam, as well as what is acceptable to take to the exam itself, i.e. coding books. June March 2009

June also raised the question of which exam we should promote for coders to take. It was the consensus of the committee that the CCS Clinical Coding Specialist exam was recommended as it includes CPT and ICD9CM for procedures and ICD9CM for diagnoses. It covers both inpatient and outpatient coding. It was decided to put the information about the different levels of testing on the Wikki site as well so that individuals could determine which test they would need to take for their type of work, i.e. CCS, CCA, CCS-P. June will put together that information as well. 8.0 What is a coding error? The HAAD has contracted with Perot to audit the coding for all healthcare providers in Abu Dhabi emirate. They will be looking at all coding, diagnosis as well as procedure coding. They will also be reviewing the E&M coding and certifying the healthcare facility once their coding meets a certain standard. Ann used Jameel s report on coding error that was circulated to all members before the meeting, to come up with a list of coding error types for the committee members to score for the coding auditors. Incorrect selection of principal diagnosis (8) Incorrect code number diagnosis or procedure (10) Error of specificity in diagnosis code; i.e. pneumonia versus bacterial pneumonia (7) Missing principal diagnosis (10) Missing additional diagnosis (7) Diagnosis coded without supporting documentation (10) Missing E code external cause (7) Missing V code as secondary diagnosis (supplemental, i.e. history of cancer) except for delivery outcome V codes, which are mandatory (5) Missing procedure code (10) Procedure coded without documentation (10) Error of specificity in procedure code (9) There was debate regarding the E code score and Ann will discuss this with Dr. Vetter for advice as well as the inclusion of incorrect selection of principal procedure since it is not a mandatory data element. Ann will now group the errors into major, moderate and minor and will forward the final results to CCSC members after meeting with Dr. Vetter. This document will then be shared with the auditors. Ann February 2009

9.0 Coding Audit Ann will be meeting with the auditors Perot and Dr. Vetter next week to discuss the audit process. The auditors will be focusing on all coding errors, as above, as well as certifying facilities for E&M coding so that they will be able to bill based on those codes. There was an issue brought up regarding E&M codes on the claims, especially for SEHA facilities. As the auditors will be using the claim for the audit, if the E&M codes are not present on the claims yet, this could present a problem. This will be discussed with the auditors as well. The coding audits will be for educational purposes only, in addition to certifying hospitals for E&M coding. The focus is to improve coding quality and accuracy, not to be a punitive exercise. Facilities will be audited in general and not by coder or physician. Trends of errors or incomplete coding will then be used to provide focused educational programs. Audit tools will be provided to facilities to conduct their own coding audits. 10.0 Confidentiality Policy Ann February 2009 The Committee members went through the highlights of the coding policies that were forwarded before the meeting. Major points were agreed upon for inclusion in the general confidentiality policy as requested by the Data Standards Panel. Ann will put these points into one document for review at the next meeting. Ann March 2009 11.0 Questions and Clarifications from HAAD A meeting was held at the HAAD between Dr. Finn Goldner, Anis and Haytham from Daman and Ann representing the CCSC. The following were the decisions as sent in an official email from Dr. Goldner s office at HAAD: In the preauthorization process, if the actual procedure performed is a logical regression or progression of the approved procedure(s), for medical necessity reasons only, no further application for approval is needed, after the fact. Ann will prepare a similar statement for diagnosis coding, through the CCSC, where the diagnosis for admission and inpatient stay extension are approved in advance by Daman and yet may change on discharge. HAAD will develop rules for validity of prescriptions (market practice until then should be extended to 30 days, i.e. pharmacy, lab, radiology, other tests). Future orders will be handled differently based on the timing of the order, i.e. patient to have echocardiogram in three months then return to clinic. Preauthorized tests have specific validity based on the dates of the authorization. Podiatrist s outpatient clinic visits will be billed as GP for service code if medically necessary,

providing their Podiatry license number as issued by HAAD licensing authority. Case Managers cannot sign for extensions of inpatient visits unless specifically licensed as case managers through the HAAD licensing authority. (Currently no such licensing). Hospitals can charge for ambulance services using HCPCS codes for covered patients, as per their agreements with Daman. The Committee members agreed the following for diagnosis coding: The diagnosis approved for admission and the subsequent complication diagnoses approved for extended length of stay for inpatients are to be considered working diagnoses and will most often be different from the final or discharge diagnoses. As long as the discharge diagnoses have a logical correlation to the approved diagnoses, claims cannot be denied because the codes are different than those that were approved for the inpatient stay. This statement will be sent to Dr. Goldner to be sent out officially from his office. 12.0 Wikki Site Maintenance Ann February 2009 Ann discussed this item with Dr. Khan before the meeting and he is ready to start working on the Wikki site with the group of volunteers. He will report at the next meeting. Dr. Khan March 2009 13.0 Stamp for CCSC with Logo Deferred Ann March 2009 14.0 Oasis Hospital Providing Education for Coders Michelea is following up on this with Luis from Oasis Hospital. Michelea March 2009 15.0 Other Business o Endorsing companies providing coding training and education. The CCSC will not endorse any company that provides coding education or training. We can pass on notification of training opportunities to our community and we can also post such on the Wikki site. The HAAD also has no certification process or licensing process for these companies and will not do so in the future. o In order to educate the consumers of what to look for in selecting a coding education program/seminar, Michelea offered to put together some tips like make sure the person giving the training is a certified coder. Michelea March 2009

Michelea will put together a document on this and we will distribute to the coding community as well as post it on the Wikki site. o Ann reported that there was a presentation at the HAAD on January 29 th on Clinical Coding A Way Forward for Abu Dhabi that was sponsored by Ingenix. The speaker talked about the uses of coding information beyond the financial benefit. This presentation was sent to all CCSC members. o Michelea offered to present a basic coding training program that she developed for the Al Noor new coders. This combines ICD9CM diagnosis coding as well as CPT procedure coding. She requested that this be sponsored by HAAD and Ann will discuss this with Dr. Vetter. o It was also suggested that a list of vendors be made available on the Wikki site. This will be discussed at the next CCSC meeting. o A question was also raised regarding modifiers for CPT codes. There is some confusion regarding whether modifiers are acceptable or not. This will be discussed at the next meeting and Ann will ask Malda to discuss it from the Payers side and June/Michelea to discuss it from the Providers side. 19.0 Next Meeting It was recommended to meet at the HAAD for the future meetings and Ann will discuss this with Dr. Vetter. The next meeting will be held on March 11 th at 10 am and the venue will be confirmed before then. 20.0 Adjournment The meeting adjourned at 12 noon. Michelea Michelea/Ann Members Malda/Michelea/June Members March 2009 March 2009 March 2009 March 2009 Major Decisions and Actions, Final and Pending for Clinical Coding Steering Committee 2009 001 Add CCSC minutes to HAAD website. Jameel Ahmed February 2009 002 Update Coding Manual and post on HAAD website. Ann Webster February 2009 003 Establish testing center for coding credentials with American Health Information Management Association in Abu Dhabi. Site identified as Prometrics in Dubai. They have agreement with AHIMA to do the testing. June will prepare document with instructions for coders interested in taking the test as well as which credential is recommended by CCSC. June Beaumont March 2009

004 Dental Coding - Dental Coding regulation changed to read When dental procedures are performed outside of a recognized dental center or dental clinic, i.e. Maxillofacial Clinic, Inpatient or Day patient surgical episodes; the Canadian Dental Association procedure codes can be used if and only if there is not a specific CPT code for the dental procedure. For avoidance of doubt: CPT code 41899 (unlisted dental procedure) is not a specific CPT code and is not acceptable in these circumstances. 005 Confidentiality Policy for HAAD Data Standards Panel Members March 2009 006 Coding error defined by Committee members. Will be refined and presented to auditors. Ann Webster March 2009 007 DOA If facility attempts to resuscitate a Dead On Arrival patient then it is possible to submit a claim for that encounter. All DOAs must be reported to HAAD in standard data submission reporting process. 008 Mixed claim with covered and non-covered services in same encounter. Ann to follow up with Data Standards Panel. 009 Statement for Pre-authorization process: In the pre-authorization process, if the actual procedure performed is a logical regression or progression of the approved procedure(s), for medical necessity reasons only, no further application for approval is needed, after the fact. Ann Webster March 2009 Approved and sent out from Dr. Finn at HAAD. 010 Modifiers to CPT codes 77 and 76. There seems to be a difference of opinion on the definitions of these modifiers and how they are being used by the payer. The definitions per the CPT book are: 76- Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. 77 Repeat Procedure by Another Physician The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service. This will be further researched by Michelea and communicated to CCSC members. Michelea Peech February 2009 Pending discussion in March regarding all modifiers. Malda Ellahham, June Beaumont, Michelea Peech

011 Reorganization of CCSC: Voting members to include 3 payer and 3 provider members: 2 SEHA 1 Private Hospitals 2 Daman 1 NAS Two sub-committees: Education Sub-committee Audit/Arbitration Sub-committee 012 Coding Audit Coding audit for all healthcare organizations by sub-contracted company from HAAD Perot to audit ICD9CM diagnosis coding, CPT4 procedure coding as well as Evaluation and Management Coding (E&M). Certify E&M coding as accurate then healthcare facility can bill using E&M codes. Voting for representation on February 24 th at coding seminar at HAAD. Audits to start in March 2009 013 Prepare health information confidentiality policy for Data Standards Panel Ann Webster - In process March 2009 014 Statement for diagnosis coding for claims: The diagnosis approved for admission and the subsequent complication diagnoses approved for extended length of stay for inpatients are to be considered working diagnoses and will most often be different from the final or discharge diagnoses. As long as the discharge diagnoses have a logical correlation to the approved diagnoses, claims cannot be denied because the codes are different than those that were approved for the inpatient stay. 015 Clarification regarding claims/billing from Dr. Goldner at HAAD: HAAD will develop rules for validity of prescriptions (market practice until then should be extended to 30 days, i.e. pharmacy, lab, radiology, other tests). Future orders will be handled differently based on the timing of the order, i.e. patient to have echocardiogram Pending distribution from Dr. Finn at HAAD, February 2009 Complete

in three months then return to clinic. Preauthorized tests have specific validity based on the dates of the authorization. Podiatrist s outpatient clinic visits will be billed as GP for service code if medically necessary, providing their Podiatry license number as issued by HAAD licensing authority. Case Managers cannot sign for extensions of inpatient visits unless specifically licensed as case managers through the HAAD licensing authority. (Currently no such licensing). Hospitals can charge for ambulance services using HCPCS codes for covered patients, as per their agreements with Daman. 016 Endorsement of coding education and training companies The CCSC will not endorse companies however we can/will pass on training opportunity information to coding community and post on Wikki site. 017 Consumer document for healthcare facilities seeking companies to provide coding education and training will be developed by Michelea Peech. Document to include tips for consumers regarding choosing the right company for the job. 018 Basic coder training for diagnoses and procedures offered by Michelea Peech, sponsored by HAAD. Complete Michelea Peech, March 2009 Michelea Peech, March 2009 019 Presentation at HAAD by Ingenix on Clinical Coding A Way Forward for Abu Dhabi. January 29, 2009 Complete 020 List of Vendors for Wikki site. All Members March 2009

HAAD Clinical Coding Steering Committee Meeting Date/Time/Place: January 14, 2009; 1:30 pm at Tawam Hospital, Lecture Hall #1 Presiding Chair: Ann L. Webster, RHIA, CCS Tawam Hospital Co-Chair: Sameera Al Hashemi, SKMC (absent) Recorder: Ann L. Webster, Tawam Hospital Present: Nestor Sibayan, Tawam Hospital; Jameel Ahmed, Western Region; Binu Paul, Mafraq Hospital; Rising for Velikakathu T. Sunil, Al Rahba Hospital; Joan Grey, HAAD; Pam Gyles, Zayed Military Hospital; Michelea Peech, Al Noor Hospital, Al Ain; Selvakumar S, Corniche Hospital; Mitchell Jesson, Tawam Hospital (Cerner); Dr. Riham for Malda Ellahham, Daman. Apologies: Malda Ellahham, Daman Insurance; Dr. Sameer Khan, NAS; Sameera Al Hashemi, SKMC; Velikakathu T. Sunil, Al Rahba Hospital; June Beaumont, Al Ain Hospital. Item No Matters Discussed & Decision Taken Person Responsible For Action Target Date 1.0 Call to order Chair The meeting was called to order at 1:30 pm. 2.0 Apologies and Guests Apologies from: Malda, Dr. Khan, Sameera, Sunil and June. Ann introduced a new member to the Committee, Joan Grey from HAAD. She is a new Data Analyst and will be a permanent member of our Committee. 3.0 Review/Revision of Previous Minutes Minutes of November 27 meeting were approved as written and posted on the Wikki by Jameel. Ann mentioned that the Data Standards Panel has requested that our minutes be placed on the HAAD website directly. This month s minutes will be put on the HAAD website after review and approval by members, as well as the Wikki site. Jameel post minutes on Wikki and HAAD websites January 2009

4.0 Update of Coding Manual and Proposal to Update Code Sets Ann is still working on updating the Coding Manual. It was also requested by HAAD that the Coding Manual be available on the HAAD website. After Ann has updated it, she will send to CCSC members for review and after approval will send to HAAD to be put on their website. Ann January 2009 Ann also discussed the proposal to update the code sets in 2010, with Dr. Vetter. He explained that if we were not making any changes this year, we do not need to do a proposal for the Data Standards Panel at this time. Ann will ask for an agreement from 3M in writing to synchronize the coding updates with the US in 2010. 5.0 Coding Seminars As June was not at this meeting, it was decided to schedule the next two months for Coding Seminars. The Coding Seminar in February will be at SKMC and in March will be at the Corniche Hospital. Future Coding Seminars for the year will be scheduled by the Education Sub-Committee, which is chaired by June. 6.0 AHIMA Coder Credentialing June and Jameel offered to contact the testing center Prometrics in Abu Dhabi to determine what details are necessary to provide the coder credentialing exams there. Jameel reported that he sent the addresses for Prometrics to June. We will follow up on this at the next meeting. 7.0 Data Standards Panel o CCSC minutes and Coding Manual will be posted on the HAAD website. o Data submission/claims changes will be effective January 15 th (one submission with the same data elements) o Additional information added to Fraud and Abuse section of Data Standards. o New Technical Advisory Committee to Data Standards Panel. o Dental Coding regulation changed to read When dental procedures are performed outside of a recognized dental center or dental clinic, i.e. Maxillofacial Clinic, Inpatient or Day patient surgical episodes; the Canadian Dental Association procedure codes can be used if and only if there is not a specific CPT code for the dental procedure. For avoidance of doubt: CPT code 41899 (unlisted dental procedure) is not a specific CPT code and is not acceptable in these circumstances. o Simplify Guidance Data Standards and Practice publication. (15 pages from 75 pages) Complete minutes of the Data Standards Panel meeting can be found on the HAAD website. Education Committee June and Jameel February 2009 February 2009

The DSP asked the CCSC to come up with a recommendation for a confidentiality policy for health information/ medical records. Ann asked all members to share their confidentiality policies for discussion at the next meeting. Ann also distributed the new data elements definitions labeled Common Types Schema from HAAD. These will be added to the Coding Manual update. Mitchell will obtain clarification of the start date for the unified data submission. Are this claims as of January 15 th or activities as of January 15 th? It was requested that Ann send an email regarding the decision on the dental codes. There was also a question regarding the dental prices, whether these include the inpatients and day patients. Ann will request clarification on this as well. Dr. Reham mentioned that there is a dental coding training on the 22 nd of January by Daman and members asked that she send the information about this to Ann to pass on to all members. 8.0 Education and Technical Subcommittee No report as June was not present. 9.0 Definition of Coding Error As no one had come up with a definition for discussion, Jameel volunteered to take this on. He will develop a definition of coding error and circulate it to members before the next meeting for discussion at the February meeting. It is important that the CCSC think about how to define an error before the company the HAAD is hiring to audit coding arrives. We want to drive this process and to do so we need to be clear as to what an actual error is. CCSC member must be prepared to discuss this at the next meeting. 10.0 Sub-Committee for Coding Arbitration No report as Sameera was not present. 11.0 Questions for HAAD At the last meeting we clarified that we can submit claims for DOA (Dead on arrival) encounters where there is an attempt to resuscitate the patient. The question was to HAAD regarding reporting all of these encounters. Ann Members Ann Mitchell Ann Dr. Reham/Ann June Jameel Members Sameera February 2009 February 2009 January 2009 January 2009 January 2009 February 2009 January 2009 February 2009 February 2009

clarified with Dr. Vetter that all DOA encounters should be reported to HAAD in the standard reporting process. This means for most facilities that these DOA encounters will have to be registered as well. 12.0 Data Dictionary Simplified and List of CCSC Decisions for Wikki HAAD has now simplified the data dictionary and this was sent to all members in soft copy. This will be added to the Coding Manual. Ann is still working on the list of CCSC decisions for the Wikki. It was also suggested by Dr. Vetter that all decisions this committee makes be numbered and listed in the minutes, as is done in the Data Standards Panel. Ann will start this with this set of minutes, at the end. 13.0 Wikki Site Maintenance Team Ann January 2009 Deferred to next meeting as Dr. Khan was not present. Dr. Khan February 2009 14.0 Stamp for CCSC with Logo Ann asked Jameel to please re-send his design so she can get the stamp made. Ann January 2009 15.0 Oasis Hospital Providing Education for Coders Michelea offered to follow up on this. Ann also mentioned that a company in the UAE has approached her regarding education and training on coding. The Committee will give guidance and provide information to these companies when requested, regarding the coding rules and standards, to support such education and training activities. 16.0 Medical Record Review by Payers There was a concern expressed at the last meeting regarding the potential for payers to request voluminous copies of medical records to review in the electronic claims environment. Ann had a discussion with Dr. Vetter about these concerns. His response was that we need to look at the issue of auditing and building trust as a package. This includes the coding audit by the company from HAAD, record review by the payers, definition of coding error, etc. This is also something that the Coding Audit Sub-committee, that Jameel has volunteered to chair, can look into as well. Jameel Michelea January2009 February 2009

17.0 Tawam Hosting E&M Training with 3M Rachael d Andrea Ann mentioned that Tawam Hospital is hosting Rachael d Andrea to come and train all physicians on E&M coding. These will be done as two hour sessions with all physicians. Additionally on the last day she will spend with the Coders going over all CPT codes and difficult sections. Ann obtained approval for all CCSC members to attend one of the physician sessions if they are interested. This will be on the first week of February, 1 through 5. She will find out if there is room for anyone else to attend the fifth day with the Coders. Ann will distribute the schedule soon to all CCSC members so they can sign up if interested. 18.0 Other Business o o Mixed Claim with covered and non-covered services. A question was raised regarding the possibility of having mixed claims where a patient has some services that are covered and some that are non-covered. Since all activities have to be reported to the HAAD, how would this occur, in one claim/submission or multiple? This question will be posed to HAAD by Ann; however Dr. Reham had a concern from the payer perspective. Daman will reject a claim by the code. If there are both covered and non-covered codes on the claim, there is a chance that the whole claim will be rejected. This will need clarification. The CCSC was asked by a member of the Data Standards Panel to come up with a statement regarding preauthorizations that require additional approvals/authorizations after the procedure because of a change to the planned procedure when it is close to the original procedure that was pre-authorized. The CCSC came up with the following statement: In the pre-authorization process, if the actual procedure performed is a logical regression or progression of the approved procedure(s), for medical necessity reasons only, no further application for approval is needed, after the fact. o A concern was expressed by the payer member regarding the above. The application for approval after the fact informs the payer of the new level of payment/benefits for that patient. If this isn t done and another facility requests pre-authorization for another procedure, it could be approved in cases where there are no more benefits available to the patient after the first procedure is paid for. This concern was discussed by the CCSC and it was agreed to make the above proposal with this concern attached. This will be forwarded to the HAAD for discussion at the next Data Standards Panel meeting. o Modifiers 77 and 76. Michelea expressed concern about the Daman use of the modifiers 77 and 76. It appears that they were not differentiating between repeat procedures by the same physician versus a different physician. Additionally there was concern that these were being used for procedures outside of the current encounter. For example a patient who had a c-section in the past. Michelea offered to obtain clarification on the official Ann Ann Ann January 2009 February 2009 January 2009

definitions for these modifiers and to communicate that to the CCSC. It is essential for the integrity of the coding system that we use the official definitions for the modifiers as well as the CPT codes. o Ann announced that Jameel has agreed to Chair the Coding Audit Sub-committee. She will meet with him to come up with a terms of reference soon and ask for members. Anyone who wants to volunteer to join his Subcommittee was encouraged to contact Jameel directly. 19.0 Next Meeting The members discussed the timings of the meetings again and they prefer not to have them the same day as the coding seminars as it makes for a very long day. They also prefer to have them in the morning from 10 am to 12 noon. It was decided to keep the meetings on the second Wednesday of the month. So the next meeting will be on February 11 th at 10 am at the Corniche Hospital. 20.0 Adjournment The meeting adjourned at 3:20 pm. Ann and Jameel Members February 2009 Major Decisions and Actions, Final and Pending for Clinical Coding Steering Committee 2009 001 Add CCSC minutes to HAAD website. Jameel Ahmed February 2009 002 Update Coding Manual and post on HAAD website. Ann Webster February 2009 003 Establish testing center for coding credentials with American Health Information Management Association in Abu Dhabi. 004 Dental Coding - Dental Coding regulation changed to read When dental procedures are performed outside of a recognized dental center or dental clinic, i.e. Maxillofacial Clinic, Inpatient or Day patient surgical episodes; the Canadian Dental Association procedure codes can be used if and only if there is not a specific CPT code for the dental procedure. For avoidance of doubt: CPT code 41899 (unlisted dental procedure) is not a specific CPT code and is not acceptable in these circumstances. June Beaumont and Jameel Ahmed April 2009 005 Confidentiality Policy for HAAD Data Standards Panel Members March 2009

006 Define coding error. Jameel to develop recommendation. Jameel - January 2009 Members February 2009 007 DOA If facility attempts to resuscitate a Dead On Arrival patient then it is possible to submit a claim for that encounter. All DOAs must be reported to HAAD in standard data submission reporting process. 008 Mixed claim with covered and non-covered services in same encounter. Ann to follow up with Data Standards Panel. 009 Statement for Pre-authorization process: In the pre-authorization process, if the actual procedure performed is a logical regression or progression of the approved procedure(s), for medical necessity reasons only, no further application for approval is needed, after the fact. Ann Webster February 2009 A concern was expressed by the payer member regarding the above. The application for approval after the fact informs the payer of the new level of payment/benefits for that patient. If this isn t done and another facility requests pre-authorization for another procedure, it could be approved in cases where there are no more benefits available to the patient after the first procedure is paid for. This concern was discussed by the CCSC and it was agreed to make the above proposal with this concern attached. This will be forwarded to the HAAD for discussion at the next Data Standards Panel meeting. 010 Modifiers to CPT codes 77 and 76. There seems to be a difference of opinion on the definitions of these modifiers and how they are being used by the payer. The definitions per the CPT book are: 76- Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure or service. 77 Repeat Procedure by Another Physician The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service. This will be further researched by Michelea and communicated to CCSC members. Michelea February 2009