On Sept. 6, the Institute of Medicine released a consensus report, Best Care at Lower Cost: The Path to Continuously Learning Healthcare in America. This report recommends five care improvement targets. One is using clinical decision support to improve knowledge. In order to do this, health information management professionals will be able to assist healthcare organizations with accurate coding and making sure health information is timely, accurate and has integrity.
The need for accurate and complete information has resulted in the necessity for health information management departments to implement coding audit processes to continually evaluate the coding accuracy and the quality of the data. Certainly, achieving coding accuracy can be complex and influenced by a number of factors, most notably clinical documentation. But health information management and coding professionals rarely work with perfect documentation that neatly aligns with language used in the classification system. The coding conventions and official guidelines must be correctly applied to achieve the highest level of reliability and consistency for coded data.
Clinical documentation has a significant effect on the level of specificity and coding accuracy achieved. Implementation of clinical documentation improvement programs, which are being increasingly employed in acute-care facilities, additionally contribute to data and information integrity. These programs enable a consistent and structured process for interface with physicians (the query process) when clarity or increased specificity in documentation is required.
The query process can be complex as it is crucial that the physician is asked for his professional judgment related to specific clinical findings. Health information management and coding professionals may not lead a physician to a specific diagnosis nor may they introduce new information that is not already a part of the health record. The codes used should fully and completely represent the patient encounter based on the clinical documentation. Diagnoses and procedures should not be inappropriately included or excluded for the purposes of determining reimbursement.
The American Health Information Management Association's Standards of Ethical Coding detail the expectations of conduct for coding professionals involved in diagnostic and procedural coding, stating the professionals should:
- Apply accurate, complete and consistent coding practices.
- Report healthcare data elements required for external reporting purposes completely and accurately in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules and guidelines.
- Assign and report only the codes and data that are clearly and consistently supported by EHR documentation.
- Refuse to change reported codes or the narratives of codes so meanings are misrepresented.
- Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment.
- Refuse to participate in or conceal unethical coding or abstraction practices or procedures.
This is only a sampling of the information contained in the Standards of Ethical Coding, but all health information management and coding professionals should be fully aware of the complete information contained in this document.
In today's healthcare environment, the use of the coded data has moved well beyond actual payment of the bill, which increases the need for coding accuracy. The CMS, other payers, states and accrediting agencies all use claims data either directly or indirectly to support quality measurement and public reporting.
That's where health information management professionals' role in data governance comes in. These institutions and others must be able to count on reliable information to drive decisions and provide quality care. It's the role of health information management professionals to make sure they can. Through ensuring data integrity and governing the collected information, health information management professionals play a critical role in not only coding, but also the entire healthcare system. The information collected must accurately and fairly represent hospital performance and outcomes of care.