CODING COMPLIANCE

1
CODING COMPLIANCE
October 18, 2002
Shana K. Wolfe, CHC, CMA Director of Business
Integrity Washington County Health System, Inc.
2
HISTORY
3
History
Coding not the basis for payment in 1965
(beginning of Medicare)
Patient volume and costs have climbed steadily
Number and types of clinical interventions has
skyrocketed
For-profit hospital chains have changed the
landscape
Managed care and focus on cost containment
DRG system in 1983, then APC system in 2000
GREED!!!
4
CASES
5
Cases
Pneumonia
Chest Pain
TIA/CVA
Cases w/cc vs. w/o cc
6
CONSEQUENCES
7
Consequences
Personal career impact
Financial loses to hospitals from fines and
penalties
BIG public relations nightmare!
Expensive corrective strategies if placed under
CIA
8
RESOURCES
9
Resources
AHIMA Standards of Ethical Coding
Guidelines of four Cooperating Parties AHA,
AHIMA, CMS, NCHS
UHDDS
Updated AHA Coding Clinics
Compliance programs and OIG guidance
Peer Review Organization Manual, section 4130
DRG Validation Reviews
10
PERSONAL
RESPONSIBILITY
11
Personal Responsibility
Adherence to Code of Ethics
QUERY PHYSICIANS!!
Participate in documentation improvement projects
The big shots go to jail, not coders (unless
there is an incentive plan tied to CMI)
12
PREVENTATIVE
STRATEGIES
13
Preventative Strategies
Support coder credentialing and continuing
education
Consider internal coding peer review
Utilize periodic third-party coding reviews
Develop a coding compliance policy
Profile your hospital coding patterns to
state/nation
Consider a documentation specialist for coding
support
Monitor your hospitals CMI
14
Thank you for your time and attention. Any
questions?