Concerned that recent disclosures about medical coding practices have "tainted the healthcare industry," the head of a coding trade group said it's time to brush up on what's illegal and acceptable when seeking maximum federal reimbursement.
Margaret Stewart, president-elect of the American Health Infor-mation Management Association, said professional ethics and expert data-handling can overcome public confusion over how medical services are billed.
Part of the confusion has resulted from an emphasis in news articles on using medical coding illegally to increase third-party payment, Stewart said. So-called "upcoding" has hit the public spotlight in the wake of federal probes involving Columbia/HCA Healthcare Corp. and academic medical centers.
Stewart said it's illegal to put down a diagnosis or procedure code that's not substantiated by the medical record. But with proper documentation, it is legal to "optimize" coding to receive the maximum payment allowed, she said.
The AHIMA is publicizing standards of ethical coding to guide people who are responsible for converting information from patient records into requests for reimbursement (See chart).
The trade group works with the American Medical Association to develop the primary system for classifying medical procedures, called CPT coding, and it cooperates with the American Hospital Association and HCFA to maintain the classification of diseases, called ICD-9-CM codes. The Chicago-based group also said it has developed materials to promote appropriate use of codes and to prevent fraud and abuse.
One article available from AHIMA discusses prevention strategies and identifies risk areas for coding fraud. It also advises coding professionals on how to respond to being pressured to commit fraud.
Healthcare organizations face new challenges as care shifts to outpatient clinics and physician offices. Coding guidelines and government regulations for those services differ greatly from inpatient settings, the AHIMA said.
In conjunction with the AMA and the Medical Group Management Association, the AHIMA has launched a certification program for medical records professionals in physician-oriented settings, from solo practices to large medical groups. The first exam for certification is Sept. 13; the application deadline is July 25.