Consistency Calls for a Coding Policy Manual

With so many different interpretations to coding rules, your practice can’t afford not to create one.

By Pam Brooks, CPC
If coding were described as a color, it would be gray. Even with CPT®, ICD-9-CM, and HCPCS Level II guidelines, and despite regulatory guidance from the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), and commercial payers, many coding rules and concepts remain open to interpretation—especially with regard to evaluation and management (E/M) coding. How can coders (particularly those working in teams) apply their interpretations consistently? The solution is a coding policy manual.

Consistency Matters

The OIG recommends each practice and facility set up a compliance plan, and part of that compliance plan should include policies regarding correct and compliant coding. Consistent billing and coding is expected across the board so patients aren’t billed differently for the same services no matter who codes the record. And uniform coding is crucial to ensure fair and reasonable physician compensation in practices and facilities where employed physicians are compensated based on volume or complexity of work—such as through a relative value unit (RVU)-based system.
In developing a coding manual, all coding rules and guidelines that currently have specific regulatory guidance should be followed. By prefacing your coding manual with verbiage such as, “It is the policy of XYZ Physician Practice that all professional fee services are coded and billed according to all current published Medicare, Medicaid, and third-party payer rules and guidance, including National Correct Coding Initiative (NCCI) edits and established documentation guidelines,” you have set the standard and expectation for all coding concepts falling under published guidelines to be followed.
The bigger challenge is determining which coding concepts are ambiguous, coming up with a reasonable directive for your staff to clarify that uncertainty, and applying a policy across the board.
For example: The NHIC (Medicare administrative contractor for Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) Evaluation and Management Coding Worksheet (form TMP-MDR-1013, July 2010) lists “drug therapy requiring intensive monitoring for toxicity” as a consideration for high patient risk. But neither the 1995 nor 1997 Documentation Guidelines for Evaluation and Management Services explain which drugs have the potential for toxicity, what frequency would constitute “intensive monitoring,” or how that monitoring would occur. The worksheet stands alone without further clarification, potentially causing uncertainty and inconsistency in the coder’s ability to determine the appropriate levels of service for E/M visits.
This scenario would translate well into practice-specific coding guidance to be used as a standard in a policy manual. With input from an existing practice policy (a list of high-risk medications that should be considered), as well as guidance from clinical staff (who determined the frequency established for ‘intensive’ monitoring), this scenario can be clarified to assist coders with determining the appropriate level of medical decision-making (MDM).

Create a Guidance Template

When creating a policy manual, a standard format is recommended. This allows for the consistent inclusion of required information, as well as guidance for creating future policies. A template—as shown in the example on the next page—will help assist the coder to capture all of the details and supporting documentation to be included in a practice-specific policy manual.
Template Example: Coding Guidance

XYZ Physician Practice

1234 Union Drive

Portland, ME 04103

CODING GUIDANCE: High-risk Medications
Coding staff will determine high-risk MDM based on the E/M guidelines. Documentation should support patient risk.
GUIDANCE: E/M auditing tools indicate that an element of MDM involving high risk can be determined if the patient is being intensively monitored for toxicity while undergoing drug therapy. Many high-risk medications require this kind of intensive monitoring. The XYZ Physicians Medication Policy MP-14.2.3 lists those medications that are high risk. They are: heparin, hypertonic NaCl, furosemide, insulin, Coumadin®/warfarin, and chemotherapy. Other medications may include Dilantin®, Synthroid®, mexotrexate (MTX) leflunomide (Arava®), sulfasalazine (Azulfidine), hydroxychloriquine (Plaquenil), etanercept (Enbrel®), infliximab (Remicade®), adalimumab (Humira®), abatacept (Orencia®), rituximab (Rituxan®), azathioprine (Imuran), mycophenolate (CellCept®), intravenous immunoglobin.
STANDARDS: High risk in MDM can be determined when a patient is receiving drug therapy that could be potentially toxic without initiating intensive drug monitoring to assure appropriate therapeutic levels. Although XYZ Physicians Medication Policy MP-14.2.3 lists medications that are “high risk,” treatment with these medications does not absolutely constitute high risk within the calculation of MDM unless the provider engages in intensive monitoring via serum levels.
Intensive monitoring is not defined; it is generally accepted by the XYZ physicians that serum levels examined no less than weekly would be considered “intensive.” Coding staff should consult a clinician for further clarification, if necessary. Documentation must support that serum blood levels having been obtained within that frequency.
Other medications not listed in MP-14.2.3 may be considered if the patient undergoes intensive monitoring for toxicity.
RESPONSIBILITIES: Professional coding staff, all XYZ employed physicians
REFERENCES: NHIC Evaluation & Management Coding Worksheet, Document # TMP-MDR-0103, 07/06/2010, XYZ Physician Policy MP-14.2.3
Under GUIDANCE, explain the rationale for the policy clarification, and under STANDARDS document any relevant regulatory guidance you’ve identified that will support your new policy. RESPONSIBILITIES will list the employees who are expected to recognize and follow the policy. Under REFERENCES, you can list web-based links, internal hyperlinks, or other references such as existing policies that support your new policy.
Document your policies on practice letterhead, and name the policy with a title that will help you search and identify it later. Remember to date the original policy, and indicate any subsequent updates.

Organize for Easy Reference

Storing your policies in a way that you can easily find, view, and reference them can be a challenge. An ideal location is a shared computer network drive that is accessible by all employees. Make sure the final policy documents are protected against inadvertent additions or changes by making the files “read only” for all staff except the administrators. You can also reformat your documents into a read-only PDF file.
A paper copy in notebook format is an alternative for small practices where a shared drive is not an option—and it’s readily available in case of a computer system failure. You also could maintain one e-copy of the manual on a dedicated computer, or have each staff member keep an updated and organized manual on his or her individual desktop or hard drive.
For the most effective manual, organize your policies in a way that identifies the type and content of the guidance. For example:

  • File your policies by topic, such as E/M, surgical specialties, and modifier usage.
  • Create files for specific payers, such as CMS guidance and Anthem guidance.
  • Create a dedicated file for office and reporting procedures specific to the billing or coding staff, such as how to run certain reports and how to set up accounts.

Having these administrative procedures in a single location can also serve as a great training and reference tool. Keeping an updated table of contents allows you to view the separate policies in each folder, but you can also use your software’s search feature to identify policies related to a specific key word. That’s why it’s important to clearly name your policies in ways that can identify the content.

Get Everyone Involved

Although coding managers typically draft and finalize the coding procedures in their practice or departments, staff coders should use their specific areas of expertise to assist in the research and recommendations of practice- and specialty-specific coding guidance. Their day-to-day coding challenges and scenarios that have no clear-cut answers are crucial and need to be part of the coding policy manual.
When problem areas are identified, research published guidelines to find existing regulatory guidance. If no specific guidance is found, or if the guidance is ambiguous, work together to find a reasonable solution and to create specific coding guidance. Sometimes it’s helpful to visit an out-of-area contractor website for direction, particularly if your own contractor’s guidance is less detailed. At the very least, you can devise more specific guidance that can be followed until your local contractor provides clarification.
Other resources include hospital or practice policy, individual payer guidelines, and guidance from professional medical associations. When your policy is in draft format, make sure it does not conflict with other regulatory guidance or existing policy. You may need to only update a current policy, rather than write a new one.

Update Often

Each year, particularly when updates occur, your procedures manual should be reviewed to determine whether changes are necessary based on more detailed regulatory guidance, new technology, etc. Occasionally, with clarification of regulatory guidance, older policies can be eliminated.
For example, prior to 2011 there was limited guidance about how to code and bill for physician observation services if the patient remained in observation longer than 48 hours. A coding policy manual prior to 2011 may have outlined the use of CPT® codes 99211-99215 for these services. With the introduction of codes 99224-99226, however, the earlier policy would need to be eliminated.
When making changes or revisions, provide a revision date and make a brief notation as to why the policy was changed. This eliminates those, “We used to do it this way, but why?” moments.
A clear and accessible coding policy manual can also assist with staff development, training, and evaluation. All coding staff should be aware of and have access to, the policy manual. Use of the manual and its guidelines should be standard for all coders; have this expectation stated in the coder’s job description. If a coder deliberately fails to follow a written policy, the manual acts as supporting documentation if progressive discipline is necessary. Should providers or administration question the methodology of the coding process for any reason, the coding policy and its references to related regulatory guidance can also help validate and support the actions of the coding staff.
A common joke heard in the health care industry is, “Coders are like lawyers. Ask two of them the same question, and you’ll get two different answers.” Until regulatory coding guidance addresses all of those gray areas of coding, a policy manual will go a long way to provide consistent coding and clarifications of practice processes.
Pam Brooks, CPC, is physician services coding supervisor at Wentworth-Douglass Hospital in Dover, N.H., where she oversees a professional-fee coding department supporting 28 practices and outpatient departments with over 100 providers. She holds a Bachelor of Science in Adult Education and Workplace Training from Granite State College, and is currently working on her master’s in Health Administration at St. Joseph’s College of Maine. She is a past secretary of the Seacoast-Dover, N.H., AAPC Local Chapter.

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