Pathology/Lab Coding Alert

Proper coding for neurosurgical 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 a neurosurgeon and a patient to insurance carriers. In an effort to recognize the level of professional excellence and the 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.

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 independant 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 wasnt documented, it wasnt done.

If a test was performed but not documented, it should not be billed, 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.

Coders occasionally are placed in the potentially uncomfortable position of educating physicians about coding practices. A pathologist 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 services provided.

AHIMAs Revised Standards of Ethical Coding

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

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 [...]