Be an Effective Coding Compliance Professional: Do You Have What It Takes?

By Ida Landry, MBA, CPC

Knowing coding and billing rules, and following them with integrity, is key to success.

Compliance is an important part of medical coding. Novice coders are instructed early on that “correct coding is the No. 1 objective,” and “if it isn’t documented, it wasn’t done.” These rules of thumb are the backbone of compliant coding for all coders. To be an effective coding compliance professional, however, you must also stay current with coding and billing regulations and have a solid code of ethics.

Certified Professional Compliance Officer - CPCO

Know How Compliance Fits into Today’s Coding and Billing

Payment is generated or denied by the guidelines, rules, and federal laws payers use to direct their part of the revenue cycle. In the past, payers acted as compliance overseers, but in recent years legislation like the Tax Relief and Health Care Act of 2006 and the Affordable Care Act of 2010 have mandated more oversight regarding documentation and coding compliance. An example of the reimbursement climate resulting from these regulations is increased scrutiny by recovery audit contractors (RACs). “From 2005 through 2008, the Medicare RACs identified and corrected over $1 billion in improper payments. The majority, or 96 percent, of the improper payments were overpayments, while the remaining 4 percent were underpayments,” according to the Federal Register, 2011, p. 57808.

A byproduct of increased oversight is the establishment of more compliance departments and restructuring in health care organizations to meet the growing need for proper coding and documentation.

Key Compliance Principles

To understand fully coding compliance and be an effective medical coding compliance professional, you must have a commitment to the core principles, rules, guidelines, and laws that embody medical compliance. This is the first objective to successfully mastering compliance elements. Another important element is adhering to a code of ethics and integrity.

These core elements can be realized through successful instruction, education, and guidance of compliant coding and documentation requirements.

Compliance Means Trust, Not Opinion

As a coding compliance professional, you should provide tangible information whenever you instruct another health care professional on appropriateness of coding or documentation. If established guidelines, specifications, and/or legislation cannot provide validation, than any guidance given is considered opinion.

Protect trust at all cost. When an opinion is given as fact and later proven to be incorrect, this is unprofessional and risky. Once trust is broken, your opinion as a coding compliance professional is no longer credible. This guidance is simple; however, there are instances in the coding community where trust is destroyed.

Trust also is abused when a compliance professional tells a coder one thing and the health care provider something different. This behavior can stem from provider pressure or a provider’s inability to comply with rules and guidelines. To prevent inconsistent information from being disseminated, present the same guidelines, rules, and regulations to all parties involved. Using information consistently also shows ethics and integrity. To maintain consistency throughout an organization, consider following a code of ethics.

Code of Ethics

AAPC has a code of ethics which addresses coding professionalism and compliance integrity. The eight components of AAPC’s Code of Ethics are:

  • Maintain and enhance the dignity, status, integrity, competence, and standards of our profession.
  • Respect the privacy of others and honor confidentiality.
  • Strive to achieve the highest quality, effectiveness, and dignity in both the process and products of professional work.
  • Advance the profession through continued professional development and education by acquiring and maintaining professional competence.
  • Know and respect existing federal, state, and local laws, regulations, certifications, and licensing requirements applicable to professional work.
  • Use only legal and ethical principles that reflect the profession’s core values, and report activity that is perceived to violate this Code of Ethics to the AAPC Ethics Committee.
  • Accurately represent the credential(s) earned and the status of AAPC membership.
  • Avoid actions and circumstances that may appear to compromise good business judgment or create a conflict between personal and professional interests.

Other places to look for a code of ethics are your compliance or coding departments. Human Resource departments also may assist you if your company has a written code of ethics.

Use Compliance Tools at Your Fingertips

You can easily find useful tools to help you attain your goals. Here is a list of some typical resources you use:

  • Office of Inspector General (OIG) website – On the “Compliance Guidelines” page, there are links to “Compliance 101 and Provider Education” and “Compliance Resource Material,” as well as other useful tools.
  • Coding books –  CPT® codebook, CPT® Assistant, ICD-9-CM, HCPCS Level II, AHA Coding Clinic for ICD-9, AHA Coding Clinic for HCPCS, OptumInsight’s™ Uniform Billing Editor, DRG Expert, and the AAPC website
  • Government coding/billing resources – Centers for Medicare & Medicaid Services (CMS) manuals; National Coverage Determinations; Medlearn Matters; the Federal Register; 1995 and 1997 Documentation Guidelines for Evaluation and Management Services; Medicare administrative contractors, Local Coverage Determinations, etc.
  • Freedom of Information Act – Used to request federal agency records not publicly available.
  • Federal acts –  Health Insurance Portability and Accountability Act (HIPAA); Health Information Technology for Economic and Clinical Health (HITECH) Act; the Affordable Care Act; Tax Relief and Health Care Act of 2006; False Claims Act; Medicare Prescription Drug, Improvement, and Modernization Act of 2003; Stark law; anti-kickback statute, etc.
  • Commercial payer resources – Look to company manuals, websites, webinars, and newsletters for guidance.
  • Company compliance manuals – Your employer should be anxious to share its compliance manuals and plans with coding and billing staff.

Being a coding compliance professional is a noble profession with ethics and integrity, knowledge of documentation and coding guidelines, and trust and validation at the core of its foundation. If you think you have what it takes to be a coding compliance professional or are thinking about becoming certified, AAPC now offers the Certified Professional Compliance Officer (CPCO™) credential. Go to aapc.com for details on how to begin this exciting journey.

Ida Landry, MBA, CPC, works for CareOregon and has worked in the health care industry since 1995. She acquired CPC® certification in 2004. Ms. Landry holds a Bachelor of Science in Health Administration and a Master of Business Administration in Health Care Management. She enjoys teaching and sharing her knowledge of coding.

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