3 Strategies for Improved Medical Coding Compliance

Posted by David Blanchard on Jan 1, 2018 10:39:39 AM
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In today’s regulatory revenue cycle climate the stakes are too high to ignore the importance of a medical coding compliance plan.  Engineering a solid plan can help protect practice professionals from penalties.  Creating and adhering to a plan can make the difference in fraud and abuse determinations. 3 Strategies for Improved Medical Coding Compliance.png

To help avoid medical coding compliance problems, experts recommend these strategies:


Clearly define your clinical clarification process

Success with ICD-10, quality reporting, and pay-for-performance programs requires accurate, correct, and specific clinical documentation.  These programs may require an increase in the amount of clinical clarification, or queries, between providers and coders to ensure alignment of clinical documentation and medical coding.  For example, a provider may assume that a coder will apply the visit level to a record, while a coder may assume that the provider will apply the correct medical coding level to the visit immediately after the patient encounter.  This process can vary greatly depending on the systems and processes being used.

These queries for clarification can be applied concurrently, pre-bill or post-bill to help ensure that clinical documentation supports the coding decisions.

A well defined and official clinical clarification query process is a good way for practices to ensure that clinical documentation is reviewed to be both complete and compliant.  Medical coders must ensure that codes capture the intent of the physician as well as all details associated with the patient’s condition, observations and treatment, among others.  Clinical documentation is a critical component as it supports practices’ revenue cycle and clinical understanding and treatment of patients and should be maintained to provide accurate details to support both.


Implement a Compliance Plan

Creating and following a documented compliance plan can make the difference between fraud and abuse determinations from auditors.

Federal, state and even private payers are increasingly focused on ensuring that payment for medical services are accurate and necessary, and they are reviewing payments to locate overpayments or intentional fraud. Violations of coding and billing rules can include anything from mistakes in billing for what are deemed to be medically unnecessary services to incorrect coding to intentionally coding claims for increased or improper overpayments.  These errors are sometimes unavoidable, but if practices have a compliance plan that encourages understanding and enforcement of billing requirements, it can help mitigate alleged intentions of fraud.  

If you have a clear compliance plan that defines how often staff is educated on compliance issues, what type of self-assessments will be performed, and how compliance issues will be reported and addressed, practices can create a solid foundation for accurate coding, billing, and reimbursement.

Training should help providers:

  • Avoid cloned notes
  • Use EHR templates effectively
  • Correct under-coding and over-coding

Document the implementation of your compliance plan, such as when and who was trained, and the efforts you took to address a potential compliance issue.


3rd Party Review of Coded Records

The last piece of this puzzle is to have scheduled reviews of your medical coding provided by a 3rd party.  These medical coding compliance reviews or audits can help identify coding and compliance issues, and give the providers information and guidance on how to address and correct them.  This can be something as simple as identifying under and over coding trends for specific physicians, incorrect modifier usage, or missing documentation.  These issues can certainly place a practice at risk of audit and penalty, but in the short term the impact to coding related denials can be immense.  The impacts to reimbursement can be painful and require additional resources or outsourced services to address.



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Topics: medical coding, Medical Coding Compliance