Oncology & Hematology Coding Alert

Proper coding for oncology procedures and practices requires up-to-the-minute information, experience and skill, as well as dedication to documenting, representing and communicating precisely what transpired between an oncologist and a patient to insurance carriers. In an effort to recognize professional excellence and great effort given by coders to provide quality service, the American Health Information Management Association (AHIMA) has revised and released its Standards of Ethical Coding.

Founded in 1928, AHIMA is an association of the clinical coders and other health information management professionals. AHIMA initially developed standards in 1991 and revised them last March. These guidelines are certainly relevant to all coders, whether coding in a physicians office or in a facility, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant in North Augusta, S.C. The two types of entities have a different focus (ICD-9 for hospitals, and CPT for physicians) as their major mechanism of payment, but these guidelines address the universal issues that are necessary for correct coding in any setting.

Essentially, the AHIMA guidelines codify a portion of the Health Care Financing Administration (HCFA) policy that was not in writing previously: If it isnt documented, it isnt done. If a test was performed but not documented, it should not be billed, Callaway-Stradley says. The AHIMA guidelines give coders a professional responsibility to help ensure such documentation and to keep abreast of the latest coding changes. A coder following the AHIMA guidelines is likely to have the information to do this.

In an era of mounting pressure on healthcare organizations to comply with regulations governing payment for services and curbing fraud and abuse, quality coding takes on an increasingly important role, AHIMA says. Because of increasing efforts by healthcare organizations, including government-funded programs such as Medicare, to ensure providers comply with payment regulations, coders are playing a larger role in ensuring their facilities dont run afoul of payment regulations.

Occasionally coders are placed in the potentially uncomfortable position of educating physicians about coding practices. An oncologist who is aware of the new AHIMA guidelines and knows that his or her coder is following these high standards should have greater confidence in the information a coder presents when billing for provided services.

AHIMAs Revised Standards of Ethical Coding

AHIMAs new guidelines present 10 points that coders should remember in all aspects of their profession:

1. Coding professionals are expected to support the importance of accurate, complete and consistent coding practices for the production of quality healthcare data.

2. Coding professionals in all healthcare settings should adhere to the ICD-9 coding conventions official coding guidelines approved by AHIMA, HCFA, the American Hospital Association and the National Center for Health Statistics; the CPT rules established by the American Medical Association; and any other official coding rules and guidelines established for use with mandated standard code sets. Selection and sequencing of diagnoses and procedures must meet the definitions of required data sets for applicable healthcare settings.

3. Coding professionals should use their skills, their knowledge of the currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes.

4. Coding professionals should assign and report only codes that clearly and consistently are supported by physician documentation in the health record.

5. Coding professionals should consult physicians for clarification and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.

6. Coding professionals should not change codes or the narratives of codes on the billing abstract so that the meanings are misrepresented. Diagnoses or procedures should not be included or excluded inappropriately because the payment or insurance policy coverage requirements will be affected. When individual payer policies conflict with official coding rules and guidelines, these policies should be obtained in writing whenever possible. Reasonable efforts should be made to educate the payer on proper coding practices to influence a change in the payers policy.

7. Coding professionals, as members of the healthcare team, should assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and the occurrence of events.

8. Coding professionals should participate in the development of institutional coding policies and should ensure that coding policies complement, not conflict with, official coding rules and guidelines.

9. Coding professionals should maintain and continually enhance their coding skills, as they have a professional responsibility to stay abreast of changes in codes, coding guidelines and regulations.

10. Coding professionals should strive for the optimal payment to which the facility is legally entitled, remembering that it is unethical and illegal to maximize payment by means that contradict regulatory guidelines.