Coding with Integrity: Top Coding Tips from AHIMA Experts

By Judy A. Bielby, MBA, RHIA, CPHQ, CCS

The demand for trustworthy data has never been more apparent than it is today, and the coding process plays a critical role in meeting the need for complete, accurate, and reliable healthcare data. Accurate and compliant coding of ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II depends on a number of components. But it always starts with a common principle-coding with integrity.

Be Mindful of Varied Data Uses

Coding is not just about reimbursement, but has many other uses that need to be considered. “Coders should focus on coding completely and accurately so that it can be used for various purposes,” notes Sue Bowman, AHIMA’s senior director of coding policy and compliance. Coded data are also used for conducting research, tracking public health, and in numerous other ways.

In fact, the International Classification of Diseases was not even designed for use in reimbursement. The inception of its earliest embodiment, the International List of Causes of Death, originated in the late 19th century and was used as a common system for describing the causes of mortality. Even the more recent revisions and modifications of ICD were not designed for use in reimbursement.

ICD-9-CM was already in use for tracking diagnoses and procedures associated with hospital utilization prior to its linkage to reimbursement systems in October 1983. While reimbursement certainly was an important consideration in the development of CPT and HCPCS Level II codes, it is not the only purpose for these coding sets either.

For consistent data, it is important for everyone to follow the same coding rules and conventions when assigning codes. Adherence to applicable coding guidelines, conventions, and instructions is absolutely necessary. Coding professionals need to keep in mind that the coded data is not only collected and used for current needs, but also stored for future use. Both current and future users of this coded data rely on the data being reported with adherence to official coding guidelines, coding rules, and conventions. Applicable data set definitions must also be followed. For example, when reporting diagnosis and procedure codes for inpatient and all non-outpatient settings, coders must follow the Uniform Hospital Discharge Data Set (UHDDS) definitions of principal diagnosis, other diagnoses, principal procedure, and significant procedures.

The importance of accurate, complete, and consistent coded data continues to increase. Coders who focus solely on coding for reimbursement can lose sight of the fact that coded data are also used for monitoring other aspects of care provided by hospitals and care providers. If coders allow reimbursement to incorrectly influence code assignment it could result in a very negative impact for the hospital or care provider beyond the threat of audits and fines. This negative impact extends to the measurement of a healthcare provider’s quality and safety, which could result in negative publicity and missed quality measures. The best way to prevent this is to be mindful that the data are used for a variety of purposes. It is best to focus on adherence to applicable code set and abstraction conventions, rules, and guidelines.

For more information on the uses of coded data see AHIMA’s Code Set Maintenance Overview webpage at www.ahima.org/advocacy/codeddata.aspx.

Know Your Sources

Coding professionals need to have a clear understanding of the authoritative sources of coding advice for each code set. AHIMA’s webpage on Authoritative Coding Advice, www.ahima.org/coding/advice.aspx [webpage no longer available], provides information on the sources of authoritative coding advice for ICD-9-CM, CPT, and HCPCS Level II code sets.

The ICD-9-CM Official Guidelines for Coding and Reporting are approved by four organizations known collectively as the Cooperating Parties-the American Hospital Association (AHA), AHIMA, the Centers for Medicare and Medicaid Services (CMS), and the National Center for Health Statistics. These coding guidelines are official as promulgated by the Cooperating Parties. Individually, these organizations do not provide authoritative coding advice on ICD-9-CM, but do so as a group, according to Ann Barta, director of HIM practice excellence at AHIMA.

In other words, articles published in the Journal of AHIMA, AHIMA newsletters, or other AHIMA resources do not introduce new official coding advice. Rather, AHIMA provides many resources to help its members find relevant coding advice in applying coding rules, conventions, and guidelines from authoritative sources.

Coding advice on ICD-9-CM is published in Coding Clinic for ICD-9-CM. The Cooperating Parties have final approval on the advice published in this resource. A timeline published by AHA Central Offices indicates that First Quarter 2014 will be the first issue of Coding Clinic for ICD-10-CM and ICD-10-PCS, and Coding Clinic for ICD-9-CM will no longer be published.¹

Coding Clinic for ICD-9-CM has a long history of being a recognized source of coding advice on ICD-9-CM. Back in 1989 the Health Care Financing Administration (HCFA, now CMS) stated in the Federal Register that the advice published in Coding Clinic for ICD-9-CM was recognized by HCFA.

The Cooperating Parties also approve the ICD-10-CM Official Guidelines for Coding and Reporting and the ICD-10-PCS Official Guidelines for Coding and Reporting. As their titles suggest these are indeed the official coding guidelines for ICD-10-CM and ICD-10-PCS.

Coding questions regarding HCPCS codes are addressed in Coding Clinic for HCPCS. This publication provides interpretation on the proper use of HCPCS Level I codes for hospital providers and HCPCS Level II codes for hospitals, physicians, and other health professionals who bill Medicare. CMS maintains the HCPCS Level II code set and has a memorandum of understanding with the AHA with regards to the purpose of Coding Clinic for HCPCS.

The American Medical Association (AMA) maintains the CPT code set. AMA publishes CPT Assistant which is the official source for CPT coding guidance.

Coders are responsible for understanding the coding rules, conventions, and guidelines. Coders should recognize that encoders and commercially published code books are helpful tools that help the coders assign codes, but these are not official sources of coding information. “They are not a replacement for coder expertise and knowledge,” Bowman says. If the encoder or book contains an error, steps should be taken to address the error. If the encoder re-sequences codes in contradiction to the UHDDS definition, steps should be taken to address this issue.

The Internet provides a wealth of information on coding topics and healthcare topics. But like other topics, not everything related to coding on the Internet is reliable. Coders must scrutinize the source of information before allowing the information to influence coding decisions. Information obtained from unreliable resources can be inaccurate. The Medical Library Association provides a useful resource on how to search for reliable information on the Internet called A User’s Guide to Finding and Evaluating Health Information on the Web at www.mlanet.org/resources/userguide.html.

Understand Code Sets’ Maintenance Schedules

Coded data is not useful if the code sets are not properly maintained. AHIMA is actively involved with several code set maintenance organizations. The AHIMA webpage on code set maintenance, www.ahima.org/advocacy/codeddata.aspx, describes AHIMA’s participation with these organizations regarding industry and standards activities. AHIMA is also actively involved in standards development activities. The AHIMA webpage on clinical terminologies, www.ahima.org/advocacy/clinicalterminology.aspx, describes AHIMA’s involvement in standards development groups like Health Level Seven, the Office of the National Coordinator for Health IT Standards Committee, and the International Health Terminology Standards Development Organisation.

Though it may seem obvious, properly maintained code sets are only useful if the appropriate versions are used. The users of coded data must ensure that the appropriate versions of the code sets and standards are utilized. Coders should be familiar with the maintenance and release timeline of each code set. Information regarding changes made to the code sets are publicized in advance of implementation so code set users can prepare for these changes. Those involved in the coding process should stay informed regarding the dates code set changes are released and publicized, as well as the dates code set changes are implemented. Tables 1, 2, and 3 provide information on these dates in 2013 for ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II. These tables describe the dates that the code set changes are published and the dates that the code set changes are implemented.

Code Ethically

Coding is a very complex process involving knowledge of coding rules, anatomy, pathophysiology, documentation requirements, payer policies, and regulations and standards. This complexity results in many challenging situations in which coding professionals must carefully review the facts in order to make appropriate, ethical decisions.

AHIMA provides guidance for ethical decision-making with the AHIMA Code of Ethics, Standards of Ethical Coding, and Ethical Standards for Clinical Documentation Improvement (CDI) Professionals. These important documents can be found online at the AHIMA Ethics webpage, www.ahima.org/about/ethicscode.aspx. Also included on this webpage are other resources such as an ethics self-assessment, case studies in ethics, and a place to report violations of the AHIMA Code of Ethics.

The AHIMA Code of Ethics is applicable to AHIMA members and credentialed professionals who are not members. The Standards of Ethical Coding provide ethical guidance to all coding professionals and those managing the coding function, not just AHIMA members and credentialed professionals. Likewise, the Ethical Standards for Clinical Documentation Improvement (CDI) Professionals provide ethical guidance to all CDI professionals and those who manage the CDI function. Those involved in the coding process should be aware of requirements to adhere to these ethical principles and standards. For example, these ethical principles and standards might be referenced in a facility’s coding compliance plan or in payer policies.

Documentation issues are especially challenging. The Standards of Ethical Coding includes guidance regarding documentation, including:

• Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.
• Query the provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (i.e., present on admission indicator).
• Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations, and official rules and guidelines.²

Similar guidance for documentation issues is provided in Ethical Standards for Clinical Documentation Improvement (CDI) Professionals.

Documentation is not the only subject of the AHIMA ethical standards. Guidance is also provided for adhering to coding rules and regulations, confidentiality, and continuing education.

Make Professional Development a Priority

Continuous lifelong learning is a must for coding professionals because of the need to remain current on changes in codes, coding guidelines, regulations, new technology, and advances in healthcare.

Coding professionals should take an active role with assisting in the development and review of policies that affect or depend on coding accuracy. Take the time to read relevant rules and regulations, and provide comments during the notice of proposed rulemaking process. The Advocacy Assistant webpage www.ahima.org/advocacy provides valuable information to AHIMA members on participating in various legislative, regulatory, coding, and standards processes.

National coverage determinations and payer policies are being updated in preparation for implementation of ICD-10-CM and ICD-10-PCS. “Coders should participate in those opportunities to comment on issues that involve coding,” says Theresa Rihanek, director of HIM practice excellence at AHIMA.

Writing and presenting on coding topics is another important component of professional development. “Write for CodeWrite,” says Kathy DeVault, senior director of HIM practice excellence at AHIMA. Individuals can also write and submit articles to their CSA’s newsletter, adds Angie Comfort, director of HIM practice excellence at AHIMA. Doing so is a great way to share expertise and knowledge with others, and also to learn about a topic in the meantime.

Notes

1. American Hospital Association. “ICD-10-CM/PCS Rollout Plans for the AHA Central Office.” Coding Clinic for ICD-9-CM. First Quarter 2013: 20.
2. AHIMA House of Delegates. “AHIMA Standards of Ethical Coding.” September 2008. 

References

AHIMA. “Statement on Consistency of Healthcare Diagnostic and Procedural Coding.” December 2007.

AHIMA. “Statement on Quality Healthcare Data and Information.” December 2007. 

AHIMA House of Delegates. “Ethical Standards for Clinical Documentation Improvement (CDI) Professionals.” July 2010.

American Hospital Association. “Official Coding Guidelines.” Coding Clinic for ICD-9-CM. Fourth Quarter 1989: 3.

American Medical Association. “CPT Process-How a Code Becomes a Code.” Accessed April 16, 2013. 

Centers for Medicare and Medicaid Services. “HCPCS Coding Questions.” Accessed April 15, 2013. h

Centers for Medicare and Medicaid Services. ICD-9-CM Coordination and Maintenance Committee Procedure Agenda. March 5, 2013.

Medical Library Association. “A User’s Guide to Finding and Evaluating Health Information on the Web.” Accessed April 15, 2013.

National Center for Health Statistics. ICD-9-CM Coordination and Maintenance Committee Meeting Diagnosis Agenda. March 5, 2013.

World Health Organization. “International Classification of Diseases (ICD) Information Sheet.” Accessed April 15, 2013.

Judy A. Bielby (jbielby@kumc.edu) is a clinical assistant professor at the University of Kansas Medical Center School of Health Professions, Health Information Management Program, and a consultant with Durst and Associates.