Neurosurgery Coding Alert

Identification, verification, and corrections are key compliance components.

Have you been worried about potential coding errors? Does the thought of an audit scare you? The answer to all concerns lies in good compliance. It is never late to think about compliance systems and put them into routine practice. Here is guidance from experts on how to build and follow compliance systems.

Why compliance programs? Compliance programs are the first and vital step to correct coding. "The establishment of a compliance program demonstrates an active interest in correct reporting and may provide you with support in the event of an audit which identifies incorrect coding," says Gregory Przybylski, MD, interim director of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "A track record of self-examination and corrective action plans should dissuade accusations of fraudulent intent."

Your practice may need checks for compliance with coding rules and guidelines to keep up best practices. This will certainly translate into better revenues. "A coding compliance program implies the practice is taking steps to regularly ensure its coding meets accepted standards," says Kent J. Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Steps to a Strong Compliance System

The Office of Inspector General (OIG) has described key components of a strong voluntary compliance program. These components rest on training, open communications, adherence to established standards and guidelines, and timely and repeated trainings.

You may like to build a coding compliance system with features that would help you enhance and keep the quality of your coding. Here are some steps that will help you build a useful compliance system:

1. Always ensure correct coding. Do not merely aim at elimination of under coding or over-reporting.
2. Make all efforts to periodically identify the problems in compliance and present remedy in coding systems.
3. Identify the potential records with compliance challenges and channelize resources to correct the problems.
4. Aim for an audit of all your records, including electronic as well as paper records. "Coding compliance does not always require electronic medical records. Paper charts can also be reviewed to identify, verify, and correct errors," Moore says. 
5. Keep an audit trail and monitor period performance of your system. "A review or audit of a statistically valid sample can be just as effective as an audit of all records and a lot more efficient. If a systematic error is identified, that may entail reviewing all other relevant records, but it still wouldn't necessarily require an audit of all records in the practice," Moore says.

The OIG speak: For the road map to compliance, you can visit: https://oig.hhs.gov/compliance/physician-education/05compliance.asp.

Focus On These Key Components

Chapter 3 titled 'Verifying Potential Errors and Taking Corrective Actions' in the Medicare Program Integrity Manual provides guidance on identification, verification, and correction of errors. An ideal coding compliance program should have features to enable each of these steps to making strong and error free claims. "If a coding compliance program does not include these steps or if these steps aren't followed, it's hard to see how the coding compliance program could be effective," Moore says.

Medicare provides guidance on criteria to build compliance systems. You can read the Medicare guidance on: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf.

According to the Medicare guidance, your coding compliance program should include the following key components:

1. The program should enable you to detect records with compliance problems. This is likely only when you have a regular monitoring of the accuracy and completeness of your coding. You may subject some sample records to a random chart audit. However, you may hazard a likely miss. You may instead establish systems for regular chart audits. This will help you to describe the code, clinical, and resource components, i.e. you can easily capture the specific codes, patient details, procedure details, and other parameters like length of hospital stay.
2. The program should have provision of review of the records identified to have compliance problems. You may employ an experienced professional for the review and correction of such errors. This will prove to be a wise investment in the long run as it will prevent may billing delays and resubmissions. Focus on coding correct. Your choice of codes should always be backed by rationale of selecting a particular code. This will also prevent you from under coding and losing revenue and over coding and inviting denials and questions. "Review at least a sample of claims to identify potential coding errors, verify that they are, in fact, errors, and correct those errors on the claims in question as well as prevent them going forward, for example through provider education and/or changing procedures or systems within the practice," Moore says.
3. You should build in the system to prevent any possible errors. Establish a system of pairing the primary and secondary diagnosis and surgical procedures done. This can help prevent any wrong combinations. "By detecting errors early and responding to them with corrective action, you should limit your financial risk and liability," Przybylski says. "An accumulation of incorrect payments for coding errors can result in a substantial financial penalty once the error is ultimately identified."
4. Establish a system that enables you to verify the original (before you make the submission), billed, and post billed versions (where you made changes, if any) of your claims. The post billed versions will help you to understand the reasons for resubmissions and take applicable corrective actions to prevent the errors from becoming a norm in your practice.
5. You should try and integrate the coding compliance system into the medical records department, if your practice has one. By doing this, you ensure compliance at the first step when the medical record is subjected to coding. "Electronic health records facilitate collection of the information, but still require the information to be examined for proper reporting," Przybylski says.
6. Maintain systems to generate sheets of your workflow as the medical coder assigns the initial codes, the computerized compliance systems suggest corrections, the corrections are implemented by the coders, the sheets are reviewed by a professional review, if applicable, and the final set of codes that is submitted.

When aiming to build compliance systems, you should make seamless efforts to train and retrain your staff. The best systems can never be a substitute for an informed and experienced coder. Invest in trainings and reviews of your staff and systems. In parallel, be prepared to meet the technical challenges. One of the key challenges can be the abstracting and maintenance of medical records in the hospitals. Ensure a smooth interface between the medical records department and help build a coding system which is based on detailed and complete documentation.

"Steps to improve training include subscribing to coding publications including CPT^® Assistant, attending coding courses hosted by the AAPC or your professional medical association, and even inviting an expert to audit the practice," Przybylski says.

Bring in Many Benefits of Good Compliance

There are several benefits of establishing a compliance system for your practice:

• It helps to reduce delays in billing
• It prevents the hassles of resubmissions
• It can translate into effective resource management
• It enhances performance 
• It guards your practice against penalties

"Ultimately, the motivation for a compliance system should be to provide accurate and timely claims the first time around," Przybylski says. "This will reduce the high expense associated with adjudicating denied claims and responding to audits, refund requests and penalties."