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Coding Policy

  1. Default Coding Policy
    Medical Coding Books
    Good morning!
    Does anyone have a general coding policy for their organization that they would like to share (or at least share parts of it)? We are trying to put together a policy so that everyone is on the same page. Ex: what is required from the physicians/providers and what is required from the coders.

    Any help would be greatly appreciated!

    Renee Grass, CPC

  2. #2
    I would love to get a copy as well if anyone is willing to share. thanks!

  3. Default
    No one has anything??

  4. #4
    Milwaukee WI
    Default Ours is pretty simple
    Physician should document what they do.
    Coders should code what is documented.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  5. Default In A perfect world!
    Yes, physicians should document what they do, and yes, coders should code what they read, but that is a duty, a task, and it is not a written policy. The Office Policy Manual, the Office Compliance Plan Educational Component should have the Compliance Officer's signed assurance that each skill level is on track with MU2. I am a consultant and right now, the biggest problem I am seeing is that doctors are contracting with large Hospital-like Compliance Officers who are mainly offsite, and not being accountable. The fact that a coder would come on and ask about a policy, knowing it is right to have, tells me the Compliance Officer in your facility/practice is not compliant. If you are told "we're looped in with such-and-such a hospital", well any individual working in any manner of health care clinical/administratrive, is non-compliant if they do not know who their CO is.

    If you were to receive a reactive OIG or CMS audit at this site, all the coders' qualifications, certifications, and Continuing Education. The MLN has detailed on-line courses on how to ensure compliance, but it is up to your CO to make sure you have ongoing, like daily training.,

    Joanne McNamara, CPMA, CPC, CMA (AAMA)

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