Medical Coding – The Importance of Following Authoritative Guidelines and References

Introduction

In this blog, we explore authoritative guidelines and references and the importance they bring to medical coding review and coding practices.

Recognized by the Medical Coding Industry

It is essential that healthcare organizations follow medical record review and coding practices which are rooted in authoritative guidelines and references as recognized by the medical coding industry. This serves to enhance the credibility and reputation of the organization, demonstrate commitment to quality, and build a foundation of compliance and integrity, while lessening the potential risk of adverse findings on coding compliance audits.

What are Authoritative Guidelines and References?

Organizations must comply with various laws, Federal regulations, and industry standards. Authoritative guidelines and references play a critical role in complying with these laws, regulations and industry standards as they provide highly trusted, reliable, and credible information that is widely recognized and accepted within the medical coding industry. They are created by experts or reputable sources and are based on research, evidence, and expertise. As a result, they provide reliable and accurate information that can be trusted, resulting in coding consistency, increased coding accuracy, and increased coding productivity and efficiency by streamlining coding professionals’ coding decisions.

Authoritative Guidelines and References in Relation to Coding Compliance Audits

When an organization undergoes a coding compliance audit, citing well-established authoritative guidelines and references demonstrates that coding is performed compliantly and in accordance with regulatory requirements.

Examples of authoritative references recognized by regulations in the medical coding industry include:

• International Classification of Diseases, Clinical Modification (ICD-CM) Official Guidelines for Coding and Reporting
• American Hospital Association (AHA) Coding Clinic for ICD-10-CM and ICD-10-PCS
• American Medical Association (AMA) Current Procedural Terminology (CPT)

In addition to the above examples, CMS provides the following authoritative references as they relate to CMS RADV coding compliance audits:

• CMS Risk Adjustment Participant Guide

• CMS Contract-Level RADV Medical Record Reviewer Guidance

Authoritative Guidelines and References – A Closer Look

We took a look at ICD and CPT codes in our blog, Accurate Medical Coding, Part 1 . Here we’ll take a deeper look at authoritative guidelines and references as it relates to accurate medical coding.

The ICD-10-CM Official Guidelines for Coding and Reporting are a set of guidelines that assist with interpreting conventions and instructions provided within the ICD-10-CM. As stated in the Official Guidelines for Coding and Reporting , “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.” They are updated twice yearly with primary updates occurring on October 1 and additional updates occurring April 1 of the following year. Annual guidelines are in effect from October 1 through September 30.

Coding Clinic for ICD-10-CM and ICD-10-PCS is published quarterly by the American Hospital Association’s Central Office on ICD-10-CM and ICD-10-PCS to provide instruction, clarification, and advice to the coding industry in relation to ICD-10-CM and ICD-10-PCS Official Guidelines for Coding and Reporting. AHA Coding Clinic Advisor states, “On January 15, 2009, the Secretary of the Department of Health and Human Services released a final rule calling for the adoption of a new edition of the  International Classification of Diseases (ICD)  standards known as the 10th edition using Clinical Modifications (CM) and the Procedure Coding System (PCS). The final rule adopted ICD-10-CM for reporting patient diagnoses and ICD-10-PCS for reporting hospital inpatient procedures, and both replaced ICD-9-CM. The use of ICD-10-CM and ICD-10-PCS applies to all “Covered Entities,” that is health plans, health care clearinghouses and health care providers, that transmit electronic health information in connection with the Health Insurance Portability and Accountability Act (HIPAA) transaction standards.” As is noted in the Federal Register, Vol. 74, No. 165 , August 27, 2009, CMS affirms Coding Clinic  as the official source of coding information.

The Current Procedural Terminology (CPT) is defined as “the most widely accepted medical nomenclature used across the country to report medical, surgical, radiology, laboratory, anesthesiology, genomic sequencing, evaluation and management (E/M) services under public and private health insurance programs. It is designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.” It is published by the American Medical Association (AMA) and is updated annually in January. By offering a uniform language for coding medical services and procedures, coding and reporting is streamlined which increases accuracy and efficiency.

The purpose of the CMS Risk Adjustment Participant Guide as a resource is to provide information on risk adjustment program processes in accordance with Centers for Medicare & Medicaid Services (CMS) requirements. It offers technical assistance for business aspects within the CMS Medicare Advantage Risk Adjustment program as well as providing training exercises healthcare organizations can utilize to assist with implementing and developing their participation in the program. The CMS Medicare Advantage Risk Adjustment program was mandated in the Balanced Budget Act in 1997 in an effort to reform Medicare payments to account for patient’s healthcare risks.

The CMS Contract-Level RADV Medical Record Reviewer Guidance has been created to provide information on the Risk Adjustment Data Validation (RADV) medical record process. These guidelines are used by coding professionals to evaluate the medical records submitted by plans to validate audited diagnoses. As stated within the Guidance , “Centers for Medicare & Medicaid Services (CMS) is legislatively mandated to risk adjust Medicare Part C payments and report a Medicare Part C payment error rate. By regulation, CMS conducts annual RADV audits to ensure risk-adjusted payment integrity and accuracy.” The Guidance further states, “In addition to this guidance, all other rules, requirements, and instructions relating to medical record documentation substantiation of diagnoses and the coding of diagnoses apply, including, but not limited to, that the supporting medical records be clear and unambiguous, the requirements set forth in Chapter 7 of the Medicare Managed Care Manual, the requirements of the International Classification of Diseases (ICD) Clinical Modification Guidelines for Coding and Reporting (ICD-9-CM), and all requirements set forth in Medicare regulations, the Parts C and D contracts, and the Electronic Data Interchange Agreements.” Adhering to the named authoritative references ensures compliance with medical record review, and coding and reporting activities.

Challenges

While a known challenge in medical coding is ambiguity of documentation, ambiguity within authoritative references is also a concern. As such, coding teams which leverage the experience and knowledge not only of individuals, but also across team members is a winning combination. Some examples of leveraging experience and knowledge include performing multiple levels of coding reviews on medical record documentation, implementing a medical record escalation process, performing ongoing coding quality reviews with resulting coder education, and offering clinical review of documentation with a medical professional.

Summary

In conclusion, following authoritative guidelines and references strengthens compliant coding policies and procedures, ensuring consistency and coding accuracy among coding professionals. By monitoring coding compliance through regular internal and external coding compliance audits, organizations can ensure adherence to legal and regulatory requirements to mitigate risk. With increased activity in CMS and OIG coding compliance audits, it’s more important now than ever before to follow authoritative guidelines and references.