Do you have policies and procedures for interpreting coding guidelines?

November 7th, 2018 / By Sheldon Barlow

Through my work as an auditor and clinical documentation improvement consultant, I have seen firsthand how healthcare organizations are structured and operate. While every organization is unique, they all have at least one thing in common: They want to provide outstanding service and quality outcomes to the patients they see. However, for physicians and healthcare organizations to stay viable in this ever-changing and complex industry, they must focus on receiving appropriate reimbursement for the services they provide.     

Studies have shown that every time a claim is touched during claims processing, the more the corresponding reimbursement is reduced due to the cost of these touches. With increased denials, additional regulation and tighter profit margins, healthcare organizations should analyze ways to reduce touches to their claims. I could write a novel on this subject, but I will limit this blog to discussing a few effective strategies. 

One strategy is for healthcare organizations to have internal procedures for interpreting CMS coding guidelines. During my time working as a coding auditor and consultant for two large healthcare organizations, I learned the value of internal policies and procedures. The first organization I worked for had an internal policy that interpreted CMS guidelines governing established patient visits. The internal policy required medical decision making (MDM) to be one of the two components evaluated for established patients. When I went to work for the second organization. it took about two months before I realized I was undercoding due to their interpretation of the same guidelines. This second organization used any two of the three components for established patients (history, exam or MDM) and did not have a written internal policy to reference. 

Because there are no definitive guidelines from CMS for this scenario, organizations should interpret these guidelines internally with the assistance of their compliance department and/or internal counsel. Neither organization was wrong—they just decided to interpret the guidelines differently. My intent in bringing up this example is not to debate which interpretation was incorrect, but to offer a real-life scenario where an internal written policy and procedure would have given me additional information on how the second organization interpreted the guidelines. 

Here are a few items to consider when setting up internal policies and procedures:

  • Internal policy documents should be reviewed and updated regularly to provide clarification to coding and billing staff when CMS does not have a definitive guideline.
  • Internal guidelines should be vetted appropriately and on a regular basis with your organization’s compliance department, legal counsel and appropriate departmental committee members.
  • Internal policy documents should go hand in hand with CMS guidelines. Obviously, definitive rules from CMS would supersede any internal policy. 

My second suggestion is to have a coding roundtable at least once a month where coders gather together to discuss coding topics. Since coding rules can be interpreted differently based on a coder’s education and experience, regular roundtable meetings can bridge gaps in understanding. For organizations with multiple coders, these meetings can promote continuity in coding and result in decreased coding denials. Here are a few items to consider when having a coding roundtable:

  • Coding roundtables should provide a safe place for coders to ask any question (there is no such thing as a dumb question).
  • Coders should be given free range to debate coding principles within the group and share different perspectives.
  • When opinions differ, coding leadership must decide the process to be followed. Alternatively, the compliance committee can be asked to weigh in on the internal policy.
  • Findings and determinations from the roundtable should be added to the internal policy documents after vetting by the compliance committee.

While there are numerous reasons for denials, and implementing these recommendations won’t eliminate all of them, establishing internal procedures for interpretation of CMS guidelines will reduce denials, increase transparency and create continuity within the coding department. Healthcare organizations that combine stellar patient care with extraordinary coding and billing practices will be successful in our ever-changing healthcare industry.   

Sheldon Barlow, MHA, CPC, is an outpatient pro fee consultant at 3M Health Information Systems.