The following information is a small portion of the coding compliance program that will affect the auditing of the
charts by the compliance department.
Coding Compliance Program for SNHU:
1. Our coding compliance is based on the values of our organization. These values include our
responsibilities:
To the patients—to provide the best, most effective, and safest treatment available
To our employees—to provide for the safety of our employees in the work environment; to make
sure our employees are properly trained to perform their tasks in a manner that is conducive to
reaching the most accurate results possible
To our stakeholders—to make sure we are using our resources wisely and being good stewards of
the resources provided for the use of the organization; to continually monitor the effectiveness of
programs to stay current with the rules, regulations, and guidelines that impact the daily
operations of our organization
To the community we serve—to evaluate the needs of the community and to ensure our
organization is providing the services needed by the members of the community
2. Our organization uses coding guidelines that have been established by the American Medical Association
(AMA) and adopted by the Centers for Medicare and Medicaid Services (CMS). These guidelines include
the assignment of:
Diagnosis codes found in the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-10-CM)
HCPCS Level I codes found in the Current Procedural Terminology (CPT) codes published annually
by the AMA
HCPCS Level II, developed, updated, and maintained by the federal government
1997 Documentation Guidelines for Evaluation and Management Services
Our staff members are to apply the guidelines found in the above documents to the coding of documentation that
is relevant in the treatment of the patients of our organization.
3. An effective coding program must be continually evaluated and monitored to ensure its effectiveness. The
goals of the coding compliance program are:
Achieving 97% accuracy in the coding of claims
Continually striving to reduce billing and claim errors
Achieving 100% of all coding staff attaining certification status
Meeting the education requirements of our coding staff
Providing training to ensure coding staff has sufficient opportunities to acquire the continuing
education units (CEUs) required to maintain their certified status
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4. To reach the above goals, the following process will be used by the staff of the compliance department:
All physicians will be audited annually and receive a score on the audit.
If the score is not 100%, the physician will be educated in the area(s) of deficiency.
If the score is 100%, the physician will be notified and given a report of the audited charts.
The charts audited will be a random selection from the encounters found in the previous 90 days.
The codes to be audited in a general audit are the ICD-10-CM diagnoses codes and Evaluation and
Management (CPT) codes used by the providers.
o These codes are 99201–99215.
All new physicians will receive a New Provider Orientation package from the Compliance
Department.
Additional information may be used by the compliance department to determine the
effectiveness of the coding within each clinic. An example of this is the use of bell curves to
identify providers which are out of the normal range of codes.
A report will be submitted to the compliance committee to provide for evidence of the
effectiveness or lack of effectiveness of the compliance department.
Areas to be covered by the education staff to improve the billing and claim errors of the clinics
will be identified.
5. Auditing charts are a very important part of the compliance department. After the charts are audited, it is
possible there may be errors that need to be corrected. The following is the process to be used to correct
errors found in the audit:
Since the claims are audited through a post-payment review, if the code billed is not supported by
the documentation in the chart, a correction will have to be made by filing a corrected claim to
the payer. This may result in a reduction in payment or an increase in payment; both ways must
be corrected.
The patient’s encounter must reflect the difference in the coding. The file must show a voided
incorrect code and a posted correct code.
The corrected claim will be then be filed to the payer. If the payer will process the corrected
claim, reversing the incorrect payment, and then paying the correct claim, there will be no need
to issue a check to correct any overpayments.
If the payer will not recoup any overpaid monies, a check must be issued to the payer for the
overpayment.
It is extremely important this process be completed within 45 days of the identification of the
error.
The above is the section of the compliance program that will be used to determine what information is needed to
evaluate the coding compliance of our facility. There are some topics covered simply as a note in the modules,
such as giving the names of new providers to the organization. Since the process above indicates a New Provider
Orientation package will be given to the new providers, the students will simply identify this in their reports.
However, on issues such as receiving or not receiving a 100% on the audits, the students will need to identify
which providers did or did not attain the 100% goal and identify where education is needed. Students will not be
required to perform the actual audits. They will be provided with information gained from an audit of charts.
From this information, they will need to determine why the provider did not meet the desired level of code. This
will be the information used in their final monthly compliance report.
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