Tailor ED Coding Policies and Procedures to Meet OIG Compliance Plan Guidance
Published on Fri Jan 01, 1999
by Caral Edelberg
EDCA Consulting Editor
President
Medical Management Resources, Inc.
Jacksonville, FL
Coders can expect to come under more scrutiny in 99 as a result of the newly released Compliance Program Guidance for Third Party Medical Billing Companies published by the Department of Health and Human Services Office of Inspector General (OIG). These long-awaited recommendations provide a detailed plan for assuring correct coding by coders, appropriate documentation by physicians, and accurate submission of claims and processing of refunds by the billing office. This months column will cover the key issues for ED coders and billing companies that handle emergency services.
Audits and Risk Evaluation
How will the accuracy of your coding be determined? Well, the OIG suggests implementation of a program for self-auditing by either someone within your billing office or by someone outside that is familiar with the coding rules for your area of coding. Emergency medicine is a particularly difficult specialty to code for and its always better to find someone with emergency medicine coding expertise to perform your evaluations.
These self-audits should evaluate your compliance with external payer policies as well as your internal coding and compliance policies and procedures. Coders should have written policies and procedures available to support the coding program and to use as a reference for auditors attempting to evaluate compliance and coding accuracy.
An effective auditing program identifies problems with documentation that may inhibit your ability to code appropriately. The physicians should be audited right along with the coders and receive feedback on how well they are complying with established documentation principles for their group as well as national standards. For example, emergency medicines most frequent challenges often are incomplete documentation of history and physical examination in the formats required for coding of each E/M level, and failure to record ED course and diagnostic interpretations so that coders can identify these services at the correct medical decision-making level.
The time spent in management of the critical patient also presents a significant documentation challenge as ED physicians often neglect to indicate the clinical conditions and time spent in management of the unstable patient to qualify for coding of the critical care services.
Emergency medicine coders often have problems understanding how to identify elements of the history of present illness (HPI) and review of systems (ROS) as separate items; how to differentiate between body area and organ system examinations under the 1995 documentation guideline rules still in force; and when to code an E/M level in addition to a procedure.
Review Claim Denials
The OIG expects to see written procedures and policies in place that specify how the coding department is to comply with proper medical record documentation and payer policies.
ED coding departments should also have a policy in place ensuring [...]
