Reimbursement Management Consultants, Inc., which provides coding support services, compliance reviews, education, and consulting, is an official exhibitor at the AHIMA20 Virtual Conference. To learn more about Reimbursement Management Consultants, Inc., or arrange a meeting with representatives during AHIMA20, please contact Kristin Gibson, coordinator, business development and education.
By Dana Brown, MBA, RHIA, CHC, CCDS, CRC, and Gloryanne Bryant, RHIA, CDIP, CCS, CCDS
“Compliance and coding ethics go hand-in-hand.” This appears to be an obvious statement. But taking a deeper look reveals there is much more to coding ethics than meets the eye.
Historically, coding professionals select a code (ICD-10-CM/PCS or CPT) for what is documented in the medical record by applying guidelines and rules.
However, with the ever-growing world of healthcare compliance, what is documented, what is coded, and what is actually treated in a hospitalization and/or encounter—even experts can differ on whether the code(s) selected are accurate.
Some time ago, an audit was performed specifically focusing on the diagnoses of Respiratory Failure (ICD-10-CM code range J96.0-J96.9), and the accuracy of MS-DRG 189. While reviewing the medical record documentation, the auditor noted there were no ABGs (Arterial Blood Gases) performed during a large number of the hospital admissions. This finding was somewhat unusual.
Another area that was unusual was that the documentation in several records did not have mention the severe signs and symptoms that are common to occur with a Respiratory Failure diagnosis. On all the charts the providers clearly documented the diagnosis of “Respiratory Failure.”
Clinically, however, the diagnosis was questioned. How did the provider know that was the patient’s diagnosis? Just because “Respiratory Failure” is documented (or Sepsis), without any associated clinical indicators—should it be coded? In the end, this facility did repay a great deal of money for the inappropriate coding/billing of MS-DRGs 189. From a compliance perspective, the coding staff knew that the coding of Respiratory Failure was inappropriate, and they had tried to get their voices heard—but no one listened.
Sepsis is another diagnosis that historically has been on the radar for government auditors and others. From the early years of the Inpatient Prospective Payment System (IPPS) in which physicians rarely documented this diagnosis (assumptions were made that a patient must have a positive blood culture to be “septic”), to consultants pushing it to be coded in the early 90s, to then being a focus of fraud investigations (over-coding) in the late 90s.
Today, there is a great deal of activity with the Recovery Audit Contractors (RACs) and private payers who are focusing on this problematic diagnosis, Sepsis MS-DRGs and the different clinical criteria used or not used to diagnose the patient.
Coding-wise, Sepsis, and specifically the rules surrounding it, are particularly challenging. Coding professionals get mixed messages and even the coding guidelines can leave them perplexed. The real issue comes down to two things: 1) Is Sepsis the Principal Diagnosis? and 2) Was it Present on Admission? Those are the key points in appropriate coding of Sepsis for the inpatient setting. Large healthcare corporations have researched and set up wonderful tools for their coding staff and/or clinical documentation integrity (CDI) Specialists to utilize in querying a provider for a possible sepsis case.
The problem now lies in the “clinical” review of encounters in which Sepsis is coded as the principal/primary diagnosis. Not only is the appropriate coding being reviewed, but also the clinical side is being addressed as well (“Did the patient really have Sepsis?”). Coding professionals are trained to code what is documented; Coding professionals are not clinicians; Coding professionals cannot challenge a provider – nor should they. A facility, institution, or practice should not be coding/billing for diagnoses that are not supported by the documentation nor supported by the care provided. It is recommended that facilities retain the services of an outside physician consultant to look at cases that are clinically questionable. Specifically, if a patient never really had “sepsis” the facility should not be coding/billing the ICD-10-CM codes for Sepsis.
Compliance needs to have a place in communicating the expectations of clinical documentation to the providers, clinicians, coding, and CDI staff. A best practice is to have written policies and procedures within the coding department that address conflicting and ethical coding issues. Ethical coding issues can be challenging clinically, politically, and from a compliance perspective as well. Outline the steps to take when an ethical issue surfaces and also address “escalation” of unanswered queries. In a true compliance approach, audits need to address both overcoding AND undercoding.
Coding professionals need to know and understand what their role is in coding compliance. Coding professionals need to be given the voice and encouragement to speak up if something doesn’t feel right. Coding professionals need to know directly what they should do, who they should bring their concern to, and if their concern is not heard, what do they do next to get their concerns addressed? In addition, it is recommended that facilities annually revisit their Coding Compliance Plan. Lastly, the AHIMA “Standards of Ethical Coding” with 11 guiding principles to help our profession serves as an excellent tool and resource.
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Dana Brown, MBA, RHIA, CHC, CCDS, CRC, (firstname.lastname@example.org), is president of Reimbursement Management Consultants, Inc. Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, (Gloryanneb@sbcglobal.net) is an independent health information management (HIM) coding compliance consultant with more than 40 years of experience in the field.
Established in 1994, Reimbursement Management Consultants, Inc. has over 20 years of coding compliance expertise in the HIM Industry. Reimbursement Management Consultant’s passion for superior customer service and commitment to excellence has made us one of the leading experts in the HIM Industry, providing coding support services, compliance reviews, education and consulting.
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