Potential Proposal for Formation of a by HC12062823529


									                Potential Proposal for Formation of a
          Coding, Documentation and Reimbursement (CDR)
                Committee Within a Medical Practice

        Given the growing presence of managed care, medical providers are under ever-increasing pressure to
scrutinize how their patterns of diagnosis and procedural coding may be improved to most effectively recover
appropriate reimbursement for services provided. Additionally, governing organizations threaten to discipline
those with documentation and coding practices that fail to comply with existing guidelines.

         Any Practice stands to benefit substantially from efforts to refine issues related to chart documentation,
reimbursement trends, and procedural coding. Fragmented attempts to address these issues can yield positive
results, but an organized approach, with attention to priority, would be far more effective. This is a proposal to
create a Coding, Documentation and Reimbursement (CDR) Committee.

        Following are several examples of potential actions by the proposed committee. Many suggested actions
may already be in full or partial effect. The proposed committee allows improved organization and oversight of
issues related to coding, documentation and reimbursement. Additionally, suggestions are made regarding
possible composition of the committee, and potential obstacles.
 Potential Actions of the Coding, Documentation, and
             Reimbursement Committee

Development of Expertise within the Practice

      Individuals with particular interests/abilities could be designated as resident experts in specific
             areas. The Practice could foster the development of those persons skills and utilize their
             knowledge for the benefit of the entire organization.

Determination of Needed Resources

      Practice sites utilize unique resources (reference books, computer software, etc.) for assistance in
              documentation and coding. Maintenance of these materials can be costly, making it
              possible that some sites may be utilizing outdated, inaccurate or incomplete information.
              CDR could assist the survey of individual sites to determine their needs.

Centralization of Resources

      CDR could investigate whether it would be in the Practices best interest to create a centralized
            set of materials that could be utilized by every site, preventing redundancy and ensuring
            that information is current and complete.

Dissemination of Information

      Requirements for documentation and coding are ever-changing. It would be helpful to have a
             common method to distribute information to each Practice site. A newsletter could be
             developed with the purpose of circulating important coding and documentation updates
             throughout the organization.

Development of Formal Policies

      Each site uses its own protocols to guide documentation and coding practice. Most are likely
             appropriate and effective, but some may benefit from informed direction. CDR could
             develop policies or guidelines to represent Practice standards.

Mastery of Common Procedures

      It is likely that a majority of the Practices charges are generated by a limited number of services.
                Since it is not realistic to expect providers to perfect their skills of documentation and
               coding for all procedures, it makes sense to pay attention to those services of greatest
               import. CDR could identify these high-impact services and provide guidance on how to
               most appropriately manage them.
Documentation Guideline Education

      CDR could assist the continued education of providers in becoming more proficient in the use of
            HCFA documentation guidelines. The primary goal would continue to be enhancement
            of guideline compliance, improvement of documentation practices and reduction of risk
            for both the individual providers and the organization.

Diagnosis Coding

      CDR could conduct investigations to determine which procedures or services are problematic
            when it comes to diagnosis code selection. Third-party payor requirements for diagnosis
            coding could be reviewed. Educational materials could then be prepared in order to
            educate providers how to most appropriately select diagnosis codes.

Procedural Coding

      It is common for care providers to misunderstand documentation and coding issues related to
              some services such as fracture care, global billing for procedural care, dermatologic
              procedures, care plan oversight, professional and technical components of procedures,
              and multiple services performed on the same day. Inappropriate handling of these
              services can lead to denied claims, and, in some instances, even be interpreted as abuse.
              CDR could develop guidelines to help manage these services most appropriately.

Non-Provider Education

      Care providers are ultimately responsible for documentation, diagnosis and coding. However
             there are many instances when nurses or other staff members are also involved. It is not
             unusual in any practice for supporting staff to assist in selecting codes for medications,
             tests, vaccinations and supplies. Additionally, nurses often contribute to documentation,
             and individuals entering charges serve as important checkpoints. CDR could assist the
             development of educational materials or protocols to help ensure that supporting staff
             members receive appropriate training in areas that affect coding and documentation.

Analysis of Third-Party Reimbursement

      CDR could examine the reimbursement patterns of various insurance carriers. Attention could
            be paid to whether the Practice is being appropriately compensated for services according
            to established fee schedules, and whether the practice abides by the regulations of
            Medicare and other carriers. Incongruities could be brought to the attention of the
            carriers for explanation.
Issues Related to Capitation

       In some capitated plans, the rate of payment (per patient per month) may be influenced by the
              complexity of the population served. Diagnosis code selection to the greatest level of
              specificity (as opposed to nonspecific codes) can sometimes demonstrate a sicker
              patient population, justifying a higher capitation rate. CDR could assess whether
              diagnosis code selection is a significant factor and accordingly develop materials to
              further educate providers on appropriate diagnosis coding.

Analysis of Denied Claims

       A significant number of any practices submitted charges are denied every day. CDR could
              direct a review of denied claims in order to guide future coding practices, possibly
              resulting in fewer denials.

Issues Related to Audits

       CDR could help conduct internal audits of documentation and coding practices to determine
             potential concerns that might surface in the event of a formal audit conducted by an
             outside organization. If any problems are identified by an audit, CDR could suggest
             methods to promptly rectify them. Familiarity with auditing procedures may also enable
             the Practice to best cooperate with, and potentially challenge the findings of, a formal
                       Composition of Proposed Committee

        The documentation, coding and reimbursement of services involves numerous individuals in assorted
positions throughout the Practice. Involvement by any of the following groups may be beneficial.

       Care providers

              Several physician and non-physician providers would be an asset to CDR.


              The actions of the committee may so directly affect organization policy that effective
                     communication with administrators would be imperative.

       Billing Personnel

              Persons with detailed knowledge of the billing system would be invaluable when investigating
                     issues that pertain to charges, reimbursement and claims denials.

       Nursing Staff

              Given that actions by nurses often impact documentation and coding, representation from the
                     nursing staff would be useful.

       Laboratory/Radiology/Procedural Staff

              Since many coding issues revolve around laboratory testing and procedures such as x-rays,
                     participation of staff performing these services may be helpful.

       Persons Entering Charges

              Individuals who submit charges serve as the most important checkpoints for each site. They are
                     able to recognize potential mistakes before charges are submitted, and (when
                     appropriately trained) may substantially reduce the number of errors.
                               Potential Obstacles


      The organization and direction of any group requires considerable effort, with this committee
             being no exception. Capable and motivated individuals would be vital to making CDR a

Recruitment of Participants

      Issues related to documentation, coding and reimbursement do not generate much interest, as
              they are often viewed as hurdles, and do not directly relate to patient care. It may be that
              there are not enough interested individuals to fashion an effective committee. Anything
              less than a team effort would be unproductive.

Suspicion by Providers

      Some Practice providers may justifiably be fearful that the committees efforts would result in
            additional intrusive regulations. It is essential that the actions of CDR be directed at
            providing valuable services, interfering as little as possible with the providers practices.

Potential Liability if the Committees Reco
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