Speaker: Laura Montalvo, BSN, RN, HCS-D, COS-C

1. Build a coding compliance program, prevent audit threats Speaker: Laura Montalvo, BSN, RN, HCS-D, COS-C

2. Objectives • Understand strategies to develop and execute a robust coding compliance program. • Utilize coder hiring/orientation tools to improve applicant selection and retention measures. • Implement a coding policy and formal coding audit process to verify competency of coders at your agency. • Understand how to remediate coders with higher than acceptable error ratings and support ongoing coding education.

3. Coder hiring/orientation plan • Candidate selection and screening considerations: • Use of certified vs. non-certified coders. • Use of RN or LVN/LPN coders vs. non-licensed coders. • Number of years of direct coding experience required in Home Health/Hospice vs. other settings. • Test scores obtained on national coding certification examinations. • Peer/panel interviewing and team selection voting. • Behavioral interviewing (tip sheet provided at end of this presentation) vs. traditional interviewing.

4. Behavioral Interviewing Tip Sheet • Tool provided at end of presentation slides. Tip sheet contains a series of questions that will help elicit actual examples of how the candidate has performed in the past. Past performance is thought to be the best indicator of future performance. • Traditional interviewing methods have some limitations since they can be very closed-ended and the answers may or may not reflect how a person will really perform/behave in the future. • Benefits of behavioral interviewing: difficult for candidate to make up stories not based on real events, can reveal a pattern of behavior, specific facts can emerge which make hiring decisions more objective.

5. Coder hiring/orientation plan • Coder job description must haves: • Clear description of key job duties/responsibilities. • Qualifications for both education and experience requirements. • Licensure and certification requirements. • Other equipment/skills required to perform the job effectively.

6. Sample Coding Job Description

7. Coder hiring/orientation plan • Coder-specific orientation plan essentials (sample plan provided at end of this presentation): • Official coding guidance and guidelines • Completion of coding scenarios from 13 tabular sections of coding manual • Appendix D review • Diagnosis coding pro-CEU’s/Interactive use • Medicare, OASIS, billing training (re-training)

8. Coding-Specific Orientation

9. Coding accuracy verification plan • Develop an accurate coding policy (sample policy provided at end of this presentation) • Sets the course for all coding activities at your agency • Delineates which guidelines are followed: ICD-9-CM, OASIS-C Guidance Manual, AHA Coding Clinic, etc. • Explains the use of query process, coder notes, and explicitly states what coders must not do according to the guidelines. • Explains coding audit processes (internal or external). • Explains claims denials, adjustments, payer coverage/medical necessity for services, as well as guidelines for compliance monitoring.

10. Sample Coding Policy

11. Coding accuracy verification plan • Coding audits • Internal vs. external • Coding audit methodology: code over code vs. record over record • External coding audit charter (sample charter provided at the end of this presentation). • Report audit format (sample coding audit spreadsheet with calculation formulas for code over code audit provided at end of this presentation).

12. Coding Audit Charter

13. Benefits of Coding Audit Charter • Keeps project on track. • Expectations are clear/documented by the customer and the auditing firm. • Can detail audit focus such as OIG, RAC, or ZPIC probe areas as well as agency-identified risk exposure areas. • Remember that it will take work and flexibility with your external auditing firm to ensure a successful engagement.

14. Coding accuracy verification plan • Coding audit costs • Variable contract rates can be negotiated with coding auditing firms based on number of records audited or based on number of coders audited (the more coders to audit may result in a price break for record audit rate). • Sample size of 30 records per coder has been chosen by our firm to constitute a statistically valid sample size. • Home Health industry coding auditing firm vs. use of an AHIMA acute facility industry coding auditing firm.

15. Sample Coding Audit Report

16. Validation of the External Audit • Ensure that your external coding audit process has a mechanism for validation of the coding audit findings. • Ensure that coding errors identified are supported by official coding guidelines, AHA coding clinic, or OASIS/Appendix D guidelines. • Coding recommendations made by the external coding auditor are best denoted in a different location of the report apart from the error report. This will minimize confusion between a true coding violation vs. recommendation for improved documentation.

17. Coder accuracy/error rates • The results of the external coding audits that have been performed for the past 2 years for each coder has yielded valuable information that changed our coding practices. • First year audit results demonstrated a marked deficit in coding accuracy among field RN and DON coders (non-HCS-D) when compared to HCS-D coders. As a result, our agency discontinued the practice of assigning final codes to claims by non-HCS-D credentialed coders. • Second year audit results continue to demonstrate a very strong accuracy rating among HCS-D credentialed coders. • Each and every coder undergoing external audit has learned from the experience and now view the process as positive and educational.

18. Coder accuracy/error rates

19. Coder accuracy/error rates

20. Coder remediation • What do you do when a coder has greater than a 5% error rating? • Coding audit summary calls and reports serve as a form of immediate coder remediation education. • Coder may sign a coder action plan that states they were educated on deficits identified upon audit. • Coder may sign that they agree with audit recommendation’s and display full understanding of education and immediately changed their coding practice that was in error. • In some instances when quality/accuracy concerns do not improve despite documented remediation, a coder may have to be transitioned through your agency’s work performance policy.

21. Coder continuing education plan • Annual subscription paid for each coder to Diagnosis Coding Pro (Home Health Specific Coding Publication) for up to 12 CEU’s approved by the Board of Medical Specialty Coding. • Decision Health Coding Interactive access (on-line coding tool) purchased for each coder. • Home Health ICD-9-CM Diagnosis Coding Answer Book (published by Decision Health) purchased annually with access to over 90 coding training scenarios and answer key. • ICD-10 Coder Training provided online for each coder (50-75 hours of training for coding associates dependent on their role). • Board of Medical Specialty Coding HCS-D renewal and re-testing requirements must be met by each individual coder to maintain active HCS-D designation at all times at coder’s expense.

22. Continuing Education Plan Paid by Agency

23. Cost-saving alternatives • Perform “blind” internal audits by existing qualified coding supervisory staff vs. hiring external auditor. • Perform a combination of internal “blind” audits and reduce the number of records that will be audited by external auditor. For instance, conduct 15 record internal audit by qualified coding supervisory staff and 15 record external audit). • Perform remediation internal audits by existing qualified supervisory staff vs. using external agency. • Negotiate “ICD-10 bundle training packages” with multiple vendors to get the best pricing and get cost savings when you have more coders to get trained. • Those affiliated with acute care facilities should reach out and piggy-back on their ICD-10 training bundles for better pricing.

24. Questions?

25. Presenter Contact Information • Laura Montalvo, BSN, RN, COS-C, HCS-D Regional Director of Quality-Louisiana & Texas CHRISTUS Continuing Care laura.montalvo@christushealth.org