task 766

Original Issue Date: 12/09/2016 Effective Date: 01/01/2017

Revision Date: 12/09/2017 Approval Date: 12/09/2016

Policy: Saint Vincent Carmel Hospital is committed and dedicated to maintain clinical coding and insurance claims, for the actual services provided to each patient, with efficiency and integrity.

Source: The official coding guidelines used will be ICD-10-CM and will follow the coding rules and guidelines included in each ICD-10-CM code set and in accordance with the ICD-10-PCS codes.

Delegation: For inpatient records, all health information management staff is responsible for the safety and security of all patient medical records and will abide by the guidelines of the ICD-10-CM codes by the documentation of the physician or provider. This will include coding reviews of progress notes, patient history, discharge summary, consultation reports, operative reports, pathology reports, lab reports, radiology reports, physician orders and nutritional assessments.

Each member is responsible for following the Indiana State Guidelines when working with records for inpatient and outpatient, as well as coding.

Procedure: When documentation is not clear on how to assign codes for the health record, it is the responsibility of the coder to contact the physician in order to receive clarification of the query. The Indiana regulations should be followed when adding new information to the patient’s health record.

When there has been an error or inaccurate code assigned and the bill has already been submitted, then their needs to be an amendment claim that will correct the information to that claim. An actual document will need to be filed and kept for records.

All ICD-10-CM codes will be reported for inpatient and outpatient areas of the hospital. The ICD-10-PCS codes will be reported for inpatient areas of the hospital only. This will allow for gathering of codes used for statistical purposes only.

Procedure for processing claim rejections will pertain to the diagnosis and procedure codes submitted by the professional coder. The reflected claims will come back to the coding staff for review.

Specifics: When Saint Vincent Carmel Hospital is reporting for outpatient claims, there must be a specific diagnosis reported. If the diagnosis is undefined, then the correct codes with the symptom, sign, abnormal test result, or clinical finding that brought the patient into the hospital.

AHIMA Standards of Ethical Coding states:

1.2. Develop and comply with comprehensive internal coding policies and procedures that are consistent with official coding rules and guidelines, reimbursement regulations and policies and prohibit coding practices that misrepresent the patient's medical conditions and treatment provided or are not supported by the health record documentation.

Reporting: For all health insurance policies, there will be specific requirements that need to be reported using the Indiana guidelines, coding policies, and standards of ethical coding.

Risks: A corrective action will be in place when there are certain risks that have been identified through audits and monitoring. There will be a specific reference to the ICD-10-CM Official Guidelines for Coding and Reporting. Certain conditions will need to be corrected during this process.

Resources: Certain coding resources that are available and used by coding professionals includes an updated ICD-10-CM, ICD-10-PCS, and CPT code books that are used by all coding professionals. There will always be a printed copy of every resource regardless of the software used. The hospitals encoder software will be available for calculation of the MS-DRG.

Process: There is a process in place for situations when a coding professional encounters and unusual diagnosis or a new procedure. The coding professional will contact both the provider and the coding supervisor for guidance and clarification. After research, the American Medical Association (AMA) should be notified of a code that cannot be identified.

Disputes: When there is a dispute between the physician and coding professional’s interpretation and official coding guidelines, then the disagreement will be sent to the manager or director of the health information management. If the issue is not resolved, then it will be taken to the medical records committee for review.

Statement: Physicians and patients will not be able to request that codes be assigned, modified, or excluded for the interest of reduced payment or reimbursement. Clinical codes will not be changed or amended per the physician or patient’s requests. The only acceptable revision is if the code assigned did not reflect the actual service rendered.

Encoders: Encoders are beneficial when it comes to our facility but must not be solely relied on. There will be manuals available and accessible at all times. Education will be provided for detection of inappropriate errors in the encoding software. Any errors will be reported to supervisor immediately.

Analysis: All medical records should be analyzed in their entirety. Codes will only be assigned when there is proper documentation form the physician. There should be a specific reason for the encounter and the conditions treated. The system will flag any codes in the computer that need to be reviewed and any inconsistencies.

Sources