It is impossible to overstate the importance of accuracy and compliance in today's coding environment. With the need to perform high quality coding as we transition to ICD-10, you may be wondering if there is a way to "bulletproof" coding. That is, is it possible to make coding impervious to challenges? Unfortunately, the answer is “NO.” There is no magic wand that can be waived, spell that can be cast, or cape that you can use to bulletproof your coding. The fact of the matter is that no two medical records are documented in the same manner and most coding clinics can be interpreted differently.
The art of coding is as fascinating as the written or dictated words within the medical record. And while you cannot bulletproof your coding, you can perhaps learn to repel some of the challenges you are sure to face. After all, even the world's most famous superhero, Superman, wasn't bullet proof as much as he was bullet repellent. So, here are a few tips to help add some “Bullet Repellent” to your code assignment.
1. Ensure Compliance: Create a coding policy and procedures that ensure compliance.
2. Educate Staff: Provide coding education to coders and CDI staff and provide documentation standards to physicians. Coders do not need to know how to document and physicians do not need to know how to code.
3. Communicate: Develop communication methods between coders, CDI staff and physicians. Good communication tools can equal better documentation with more accurate code assignments.
4. Monitor: Audit and monitor physician documentation and coding assignments. Focus on the OIG work plan, high volume DRG’s, rebellious physicians, DRG’s with no CC/MCC, etc.
5. Review: Put in place a pre-bill review that can enhance your monitoring and provide an extra measure for those DRGs that have been reviewed by the RACs.
6. Give Feedback: Have an action plan to give praise or take corrective action as needed.
7. Repeat: The education, monitoring and review process should be continuous and cycle the through the organization's review plan.
The Bullet Repellent method is never ending. There’s always a new twist around the corner. It might be a new way to document a diagnosis or procedure, a new code could be added (when the powers that be decide it’s time to move on to the next system) or a different interpretation of an old Coding Clinic could be entertained. No matter the obstacle, research and education is the key to maintaining accurate and compliant documentation and coding.