AHIMA takes hard line on illegal upcoding
It’s time to start restoring trust
If the feds catch you illegally upcoding your DRGs to boost reimbursement, don’t expect sympathy from the American Health Information Management Association (AHIMA).
The Chicago-based group is taking a hard-line approach to anyone caught in the federal upcoding investigation. "Any health care provider or payer who knowingly violates the laws, regulations, or ethical principles governing coding should be punished to the fullest extent of the law," says Margaret M. Stewart, RRA, president-elect of AHIMA.
Still, Stewart says she believes the attention the press has been focusing on upcoding investigations does not reflect what’s happening in health care. "For the most part, I don’t believe this is true. However, every field does have a few bad apples," she says.
Stewart says the articles have caused confusion about the differences between what is illegal and what are acceptable coding practices. It is illegal to code for diagnoses that are not substantiated. On the other hand, with the proper documentation, it is legal to optimize coding in order to receive the maximum payment allowed.
"Whether or not these articles are accurate isn’t the point. They’ve tainted the health care industry," Stewart said. "We all have to work harder to protect the integrity of health information if we’re going to restore the public’s faith in us."
AHIMA’s Council on Coding and Classification has developed standards to give medical coders ethical guidelines. The standards include:
• proper training of coding staff;
• developing up-to-date, comprehensive internal policies and procedures for coding and billing;
• implementing quality audits;
• evaluating internal coding policies;
• comparing diagnosis codes with procedure codes;
• comparing diagnosis and procedure codes with documentation in medical records;
• documenting physicians’ clarifications;
• providing information on new laws or regulations affecting coding;
• reality checking before implementing consultants’ recommendations;
• comparing facilities’ DRG distribution with national data, and physicians’ E & M code usage with others in the same specialty and region;
• evaluating claims denials;
• examining organizational data over the past several years to determine inconsistencies;
• informing legal counsel if colleagues are committing or making errors that could lead to fraud and abuse charges.
By mid-June AHIMA expects to have available its Payer’s Guide to Healthcare Data Quality and Integrity. This manual is designed to educate payers about national coding guidelines and their relationship to national data quality and comparability. The manual also will highlight how the inconsistent application of coding guidelines is eroding the quality of healthcare data.
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