by Marge McQuade CMSCS, CHCI, CPOM
December 12th, 2017
The financial health of every medical practice rests upon correctly coded claims. This is true from not only a financial standpoint since coding drives reimbursement, but from a compliance perspective as well. All of the resources available for coding information and guidance are meaningless without the practice manager sifting through all of the information and translating it into provider-specific coding and billing guidelines and policies.
The development and use of well-documented comprehensive coding and billing policies will provide consistency, accuracy and reliability of the coded data in the practice’s database, assure sound and ethical coding practices, and provide back up if coding practices are questioned by third party payers.
In addition to the practice manager and physician, the coding/billing staff should be included in creating the guidelines and policies and procedures. This is extremely important to help identify areas where staff may have questions or unclear guidance.
Guidelines may be organized in any format. Depending on your practice, your guidelines may need to address several different types of coding and billing, such as office, inpatient hospital, and ASC (ambulatory surgery center).
One of the first things that needs to be done is to identify all coding issues addressed in National Correct Coding Initiative (NCCI) that pertain to your practice. Also identify all issues not addressed clearly and comprehensively by the NCCI guidance and develop practice specific guidelines for those issues needed for your practice to code and bill correctly and efficiently
Just as no practice should have a “canned” compliance plan, no practice should have “canned” coding policies. Some of the important areas to cover are:
A. Ethical Standards of Coding – your guidelines should reference your practice’s Standards of Conduct that apply to coding and billing tasks specifically.
B. Documentation Policy
- Cardinal Rule for All Coding: If it isn’t documented it wasn’t done!!!
- Medical Abbreviations
- Medical staff approved to document
C. Physician Query Process
- When it is acceptable to query the physician
- Criteria for a "valid" physician query
D. Billing Processes
- Entering patient information
- Entering CPT & ICD-10 codes
- Transmitting claims
- Review/correct errors, resubmit rejected claims
- Posting payments
- Reviewing patient accounts
- Follow through on delinquent claims
- Monthly reports needed for review
Once you have completed your billing & coding guidelines and policies it is import to provide your staff with copies as well as conducting education on the guidelines. The OIG has made it very clear that it sees coding and billing as currently the biggest compliance risks for every health care practice. Your practice should use your coding & billing policy manual as well as your compliance plan as a basis for ongoing education and training of your coding/billing staff. More importantly, the practice manager should keep records of the education sessions and document the content of the meetings as well as who was in attendance. These records will serve as evidence that the coding staff understood and was familiar with the organization's coding manual and compliance plan. Like HIPAA and OSHA this education should be done annually.
The process to create a billing and coding policy manual will be very time consuming. But remember, the benefits (in terms of correct billing and compliant coding practices) will definitely exceed any time that may be associated with the development of the guidelines and policies & procedures.