The importance of accuracy and compliance in today’s coding environment cannot be overstated. High-quality coding is always a priority – but is there a way to make coding impervious to challenges? Unfortunately, the answer is “NO.” There is no magic wand that can be waived, spell that can be cast, or cape that you can use to ensure your coding program is invincible. The fact of the matter is that no two medical records are documented in the same manner and most coding clinics can be interpreted differently.
The art of coding is as fascinating as the written or dictated words within the medical record. And while you cannot bulletproof your coding, you can perhaps learn to repel some of the challenges you are sure to face. After all, even the world’s most famous superhero, Superman, wasn’t bullet proof as much as he was bullet repellent. So, here are a few tips to “armor up” your code assignments.
- Ensure Compliance: Create coding policies and procedures that ensure compliance and require authenticated acknowledgement annually by your staff.
- Educate Staff: Provide coding education to coders and CDI staff and provide documentation standards to providers.
- Communicate: Develop communication methods between coders, CDI staff and providers. Good communication tools can equal better documentation with more accurate code assignments.
- Monitor: Audit and monitor provider documentation and code assignments pre-bill. Focus on the OIG work plan, high volume DRG’s, rebellious physicians, DRG’s with no CC/MCC, etc.
- Give Feedback: Have an action plan to give praise or take corrective action as needed.
- Repeat: The education, monitoring and review process should be continuous and should promote provider and coder performance improvement.
Don’t ever let your guard down, there’s always a new twist around the corner. It may be a new way to document a diagnosis or procedure, new codes added or a different interpretation of an old Coding Clinic being entertained. No matter the obstacle, education, communication and monitoring are key to maintaining accurate and compliant documentation and coding.
This article was originally published on himagine solutions and is republished here with permission.