Payment Error Prevention
Hospital Coders and Physicians Should Work Together to Support Compliance

Since its inception, one of the major challenges of the Centers for Medicare and Medicaid Services' (CMS) Payment Error Prevention Program (PEPP) has been documentation and compliance. Under PEPP, state peer review organizations review physician services to help identify and reduce improper Medicare payments.

Physicians constantly face compliance issues from many disciplines: health information management, coding and reimbursement, quality improvement, resource management, and so forth. Physicians must continually reaffirm the importance of quality documentation, data integrity and accuracy that are crucial for timely billing and medical appropriateness.

So how can physicians and coders work together to facilitate compliance in this pressure-cooker atmosphere? The key is to seek help from those most conversant with the current reimbursement system and provide input and feedback to improve the system.

Communication is Key
Unfortunately, in attempting to bridge the physician-coder communication gap, coders have been known to become frustrated with physicians who may express anger at both the coder and the coding system alike. As a result, coders frequently feel that they don't receive appropriate professional recognition.

Physician experts in the documentation field suggest a few "pointers" for improving the communication between departments responsible for protecting the integrity of the medical record.

To achieve maximum positive two-way communication, try to perceive the issues from the other's perspective:

• Basic coding rules, such as the principal diagnosis versus admitting diagnosis, are important. While coders need to be assertive in communicating official coding rules, clinical judgment always remains the purview of the physician. Recognize that rules governing the selection of the principal diagnosis can differ between the inpatient and the outpatient environment, and acknowledge that the coders are the compliance experts in this area.

Bottom Line for MDs
The medical record is a clinical communication tool but it is also the ultimate source for billing and audit. All physicians have a fiduciary responsibility to document in a manner that ensures accurate and appropriate facility reimbursement.

Documentation in the medical record must begin the moment patient care is initiated and lead through a reasoning process to develop the best diagnosis as information from the laboratory and the clinical course become available. The resulting principal diagnosis, now supported by a logical argument in the progress notes, allows for more accurate coding and billing.

As a peer review organization, MassPRO relies solely on the medical record to make initial review determinations. We reiterate the old saying, "Physician thoughts don't photocopy well." Document your rationale!

Changing long-established behaviors is seldom easy, but if coders and physicians can help each other, the patient will ultimately benefit. Currently, coding and documentation are being introduced sooner in professional training, and new physicians will see far more emphasis on documentation early in their careers.

– Christopher G. Richards
MassPRO's PEPP Program