PWS_Attachment_III_Coding_Program_Management_and_Training_Guidelines.pdf

Bureau of Medicine and Surgery 2300 E Street NW

Washington, DC 20372

Coding Program Management and Training Guidelines

Version 2.0

6 December 2010

CODING PROGRAM MANAGEMENT AND TRAINING GUIDELINES

1. Purpose

2. Background

3. Responsibilities

4. Guidance

a. Coding

(1) Identifying Coding Requirements

(2) Monitoring Coding Productivity

(3) Validating Coder Productivity

(4) Remote Coding Discrepancies

(5) Impediments to Coding Productivity

(6) Systems Down Time Back-up Plan

b. Auditing

(1) Frequency

(2) Scope

(3) Methodology

(4) Timeliness

(5) Auditor Productivity

(6) Audit Results

c. Training

(1) Frequency

(2) Development

(3) Scope

(4) Scheduling

(5) Assessing Training and Monitoring Effectiveness

Reference (a): Chief, BUMED memo 6150 Ser M3/5 HCS3/AT-57506 of 23 Feb 10 (NAVMED Policy 10-001) (http://www.med.navy.mil/policy-guidance/Documents/NAVMED%20POLICY%)

1. Purpose. The purpose of this document is to revise the Coding Program Management and Training Guidelines to more effectively utilize coding contract services.

2. Background. The Multiple Award Task Order (MATO) coding contract was designed as a "performance based" contract, establishing benchmark indicators for quality, accuracy and timeliness of coding, as well as auditing and training. Close coordination and leadership support will enable commands to maximize production and optimize utilization of the services available under this contract. Use of the MATO contract is highly encouraged to support optimal coding accuracy, auditing and training needs.

3. Responsibilities.

a. BUMED M3/5 HCO3: BUMED M3/5 HCO3 (Health Information Management

Department) will develop the Coding Program Management and Training Guidelines, for use by the Region Commands and participating Military Treatment Facilities (MTFs).

It includes general guidance and a program management checklist of scheduled tasks to improve coding program management.

b. BUMED Project Management Office (PMO): The BUMED PMO will work with MTFs and Region Commands to identify and validate coding weaknesses. The PMO will work collaboratively through charted workgroups to resolve identified issues and to prevent their reoccurrence.

c. Naval Medical Support Command (NMSC): NMSC will serve as the Contract Officer Representative (COR) for the MATO Coding Services Contract and communicate directly with the contract vendors, Naval Medical Logistics Command (NMLC) and Fleet and Industrial Supply Center (FISC).

d. MTF Region Commands: MTF Region Commands will appoint a Coding Contract Region Program Manager (Region PM) to monitor management, utilization, and execution of the coding contracts for sites under their cognizance. Region PMs will communicate directly with MTFs, the NMSC COR, and NMLC to mediate any contract issues or concerns.

e. MTFs: MTF Commanders, Commanding Officers, and Officers in Charge, will appoint a Coding Contract MTF Program Manager (MTF PM) to develop business practices to optimize management, execution, and cost-effectiveness and efficient utilization of the coding contracts in order to meet established goals and Task Order (TO) requirements.

f. MTF PMs: MTF PMs will ensure coding, auditing, and training occur within the scope of work agreed upon by the contractor and the Department of the Navy as indicated on their TO and corresponding basic MATO contract. The MTF PM will closely communicate with the Invoicing Authority, and the appropriate MTF Region Command Coding Manager’s Patient Administration Departments (PAD) to ensure resolution of http://www.med.navy.mil/policy-guidance/Documents/NAVMED%20POLICY%25 http://www.med.navy.mil/policy-guidance/Documents/NAVMED%20POLICY%25 invoice discrepancies.

g. International Classification of Diseases, 10th Edition (ICD-10) Implementation. The

MHS is evaluating systems and requirements to meet ICD-10 implementation dates.

The contractor is responsible for ensuring their staff is fully trained to implement coding practices that comply with ICD-10 requirements by the implementation date established by the Department of Health and Human Services. Beginning 1 October 2013, ICD 10th Edition, Clinical Modification (ICD-10-CM) and ICD 10th Edition, Procedural Coding System (ICD-10-PSC) codes will be the standard code sets used in the United States and the MHS. This will be the code set used by contracted staff in the MTF to code records, develop training, conduct audits, and maintain certification.

4. Guidance. The MATO contract provides remote and onsite coding, audit and training services. It engages coders, auditors, and trainers to improve execution of the MTF’s coding program. It is the responsibility of the MTF to ensure coding, auditing, and training occur within the scope of work specified in the basic MATO contract and applicable corresponding TOs.

a. Coding: The coding aspect of the contract can be performed onsite or remotely.

Coding services must remain within the volume indicated on the TO. If you anticipate not meeting or exceeding the indicated volume, please contact your Navy Medicine Region PM immediately.

(1) Identifying Coding Requirements. The most efficient use of coding contract dollars is to focus on the following clinical encounters:

(a) Billable Care to include Medical Services Accounts (MSA), Depletion, Depreciation and Amortization (DD&A), and all Other Health Insurance (OHI).

A certified coder must code OHI records prior to the claim being submitted for payment.

(b) Relative Weighted Values (RWPs).

(c) Ambulatory Procedure Visits (APVs).

(d) Complex care/High level Relative Value Unit (RVU) encounters: contract coding assets should be used in clinical areas that produce complex encounters and for which a high level of coding expertise is needed. MTF Points of Contact (POCs) are encouraged to work closely with their Command Data Quality and Clinic Manager to determine thresholds for complex care/high RVUs.

(e) Historically problematic areas (i.e., Wellness Exams), focused efforts to establish improved documentation and the development of templates/forms can improve overall coding accuracy and data quality.

(2) Monitoring Coder Productivity. Contractors base their prices on the volume of encounters coded. If your TO indicates 5000 records a month are to be coded but the MTF only provided 1000 records, the contractor may be entitled to compensation if they incur costs based on the original ordering volume. Therefore, it is the responsibility of the MTF coding program manager to ensure productivity levels are being met by the contractor. To do this, the program manager will:

(a) Ensure coders consistently receive complete medical records for coding. Your coding contract staff is NOT responsible for compiling, tracking down missing information/reports or traveling from clinic to clinic to retrieve or collect records.

This is the most significant impediment to coder performance and productivity.

(b) Monitor productivity by using weekly coder productivity logs provided by the contractor.

(3) Validate coder productivity. Develop a mechanism to validate local and contractor provided coder productivity logs against a reliable productivity report source--e.g., Composite Health Care System (CHCS), Coding Compliance Editor (CCE), or Armed Forces Health Longitudinal Technology Application (AHLTA) canned or ad hoc productivity reports. When validating productivity, only include coded encounters. Do not include encounters presented but resulted as uncoded encounters.

(a) An encounter is considered "coded" once a certified coder reviews, either handwritten or electronic medical record documentation, and assigns ICD-9- CM, Evaluation & Management, Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes, required modifiers, units and diagnosis links based, upon the reviewed documentation and recommended edits from CCE (if available).

Example 1: Coder productivity log indicates 120 encounters given to a coder for coding.

110 encounters are coded, 7 are queried to physicians to obtain additional information, and 3 are not coded because they do not contain documentation to support coding. The total encounters coded = 110, not 120. The invoice for this coder for this date should be listed as 110 encounters multiplied by the unit price for coding.

Example 2: When utilizing the CCE Productivity for Coder by Encounter Coding Status report: Only include "Complete" encounters indicated in "Enc Coding Status" field as production value.

All other encounters are considered “Incomplete” or “uncoded."

(4) Remote Coding Discrepancies. If your facility does not agree with the code assigned by the contractor's personnel, the facility shall notify the contractor of the determination immediately via electronic e-mail with a copy to the facility’s Region PM and NMSC COR. The contractor shall respond within 48 hours as to the action they will take (e.g., recode the encounter, request additional information from your facility, explain why the encounter will not be recoded, etc.). In turn, the facility shall respond within 48 hours, in writing, as to whether the contractor's response is acceptable. Inform and copy your Region PM and the NMSC COR on all correspondence related to this discrepancy.

(5) Impediments to Coding Productivity. Identify and remove impediments to improving productivity and performance. This will allow you to better manage your coding contract.

(a) Develop and implement a reporting mechanism for coders to communicate impediments that prevent them from meeting contracted productivity requirements.

(b) Develop an obstacle resolution process to ensure that impediments are removed expeditiously. Identify an Issues Resolution Group which includes coding staff, IM/IT staff, and AHLTA clinical coding champion.

(c) Develop a log that will allow you to track all identified impediments and the status of their resolution. When completing your log, be sure to answer the following questions when describing the identified obstacle:

Is it a process or systems issue?

How does it impede productivity?

How many encounters does it affect?

(6) Downtime Back-up Plans: Ensure that a back-up plan exists to address system downtimes. It should be anticipated that computer systems have scheduled and unexpected downtimes which will affect coding productivity. When systems are down, the requirement for the contract coder to meet daily productivity levels remain intact. Coordinate with the appropriate Region PMs to ensure a comprehensive back-up plan is in place and is effective. Incorporate your back-up plan as a section of your MTF Coding Compliance Plan. Develop a back-up plan for:

(a) Scheduled system downtimes.

(b) Unscheduled system downtimes.

b. Auditing. Auditing supports your data quality requirements as well as detailing areas that require additional intervention for improved documentation and coding output.

Refer to your TO to determine the number of encounters to be audited.

(1) Frequency. A minimum of 12 audits will be conducted annually by the MATO contractor; recommend a minimum of one audit monthly.

(2) Scope. 10 percent of all records for a given category should be audited in order to have a valid sample size; up to the maximum stated in the TO.

(3) Methodology

(a) Random Audits. Audits are based upon a random selection from one date of service. (A snapshot of all of the services rendered on one day at an MTF.

All clinics, all providers, all encounters).

(b) Focused Audits. A focused audit is based upon a single criterion (e.g. code, a range of codes, a provider, or a department). The focus of audits will include, but not be limited to: Relative Weighted Products (RWPs) and Relative Value Units (RVUs) recapture, and provider query.

(c) Mandated Audits. The methodology is identified specifically in guidance or policy (e.g., BUMED Monthly Data Quality Management Control audit).

Additionally, the focus of the audits will include, but not be limited to: RWP and RVU recapture, provider query, clinical documentation, Evaluation & Management (E&M) coding, and interpretation of coding guidelines.

(d) Auditing performed by the auditor/trainer should be standardized and uniform in accordance with reference (a).

(4) Timeliness. Ensure all necessary system access and documents are available in advance for the auditor. Your contract auditor is NOT responsible for collecting or retrieving material to be audited.

(5) Auditor Productivity.

(a) Document all auditing activities by developing an audit productivity form;

similar to coding productivity forms.

(b) Develop a reporting mechanism for auditors to report and identify obstacles to auditing productivity.

(6) Audit Results. Ensure you receive audit results from the contractor no later than the fifth business day of the preceding month.

(a) To assess the quality of the audits and performance of the contractor, MTFs will establish a system whereby a government coding supervisor reviews the audits of the auditor/trainer. This will be done to ensure the integrity of the audit and avoid a conflict of interest.

(b) Each audit will provide recommendations for training to the government supervisor. RVU and RWP rates, as applicable, before and after the training should be monitored for effectiveness of the audit/training process.

(c) Discrepancies. If you identify discrepancies with the audit results notify the contractor, via electronic mail, immediately with a copy to your Region PM and NMSC COR. The contractor shall respond to the government supervisor within 48 hours as to the action they will take (e.g. re-audit the encounter, request additional information from the government supervisor, explain why the encounter will not be re-audited, etc.). The government supervisor will respond within 48 hours, in writing, as to whether the contractor's response is acceptable. Inform and copy your Region PM, the NMSC COR and NMLC on all correspondence related to this discrepancy.

(d) If there are coding disagreements between the coder, provider and auditor, they should be resolved locally via the MTF Coding Supervisor or Region PM.

c. Training. Identify your training requirements.

(1) Frequency. Refer to your TO. The auditor/trainer will train the residents and interns, as applicable, a minimum of 3 times annually. These individuals can be trained in conjunction with staff providers and should be included in all training affecting their clinical specialties.

(2) Development. Each command will develop an annual coding training plan, to include training of providers and coding staff. Training plans will be based upon audit findings, to include the recovery audit. The auditor/trainer will provide training proposals to the coding supervisor, and then work with the coding supervisor on the final plan. It is up to the MTF leadership to finalize the coding training plan, in accordance with BUMED Guidelines as stated in reference (a). Additionally, future guidance will be published from the results of the Program Management Office’s Training working group.

The contractor shall develop a coding curriculum that is tailored to the specific services provided by each MTF. The contractor shall work in conjunction with the government and the electronic health record trainers to develop or use standardized BUMED training materials utilizing the following core curriculum items.

Current ICD, to include ICD-10 implementation, and CPT codes and conventions

Inpatient and outpatient documentation

RVU/RWP documentation and coding

Residency specific issues (as applicable)

Use of HCPCS and CPT codes

Inpatient and outpatient documentation

Inpatient and outpatient query form process

MS-DRG validation

Changes in industry coding conventions and nomenclature

Industry coding classification updates

The contractor shall ensure the training materials are continuously updated to provide the most current and relevant information available. The curriculum shall include specific information and examples relevant to the clinical area for which the training is provided. The intent is to intermingle the audit results with the curriculum.

(3) Scope. Training shall be based upon audit findings. The focus of training will include, but not be limited to: RWP and RVU recapture, provider query, Coding Compliance Editor (CCE), clinical documentation, E&M coding, and interpretation of coding guidelines.

(a) Each MTF will determine how to implement provider query, in accordance with the

Project Management Office Provider Query work group chartered November 2010. The plan will be communicated to leadership, and training developed with the intended audience being coders, providers and appropriate clinical staff.

(4) Scheduling. It is the MTF’s responsibility, not the contractor's, to develop the training schedule based on input received from the auditing program. Develop the training schedule in advance to accommodate provider schedules. Ensure that the training location is identified; your intended audience is available, and schedule as far in advance as possible.

(5) Assessing Training and Monitoring Effectiveness. It is the responsibility of the coding program manager to ensure that training by contract personnel occurs within the scope of the MATO contract and applicable TOs.

(a) Develop an introductory coding course for interns and residents to be completed during their facility orientation. The coding supervisor will coordinate training with command Graduate Medical Education (GME) personnel to obtain a session on intern and resident orientation. If no such orientation exists, the supervisor will work with the GME staff to ensure this type of training is scheduled in another venue. This training should include coding POCs, an overview of how coding is processed at the command in terms of roles of the provider and the coder, provider expectations for coding and importance of timely coding and documentation.

(b) An introductory coding session will be included in command “O” or other similar orientation with providers as he/she checks on board, so that the provider is aware of coding processes and POCs at the command.

(c) Identify obstacles to training, if any. The MTF Supervisor will direct and pave the way for the coder/auditor/trainer to establish relationships within the MTF.

Once the contractor becomes familiar with the POCs and the MTF processes for scheduling training, there should be less reliance on the government supervisor for setting up training sessions, scheduling rooms, and discussing potential training times and dates with the clinics. This does not negate the need for the government supervisor to oversee the scheduling and training plan. The first training session that the coder/auditor/trainer conducts should take place no later than 30 days after the completion of coder/auditor/trainer’s own required training.

(d) Develop a reporting mechanism for trainers to communicate obstacles that prevent them from meeting training requirements.

(e) In accordance with the terms of the MATO contact, the contractor shall evaluate the effectiveness of the training provided. The contractor shall develop a short questionnaire with no more than seven feedback questions that permit the student to evaluate and rate the effectiveness of the training that was given to the student. To determine the effectiveness of the training, the respondent shall answer at least 70 percent of the questions. The contractor shall obtain Government approval prior to using the questionnaire and the same questionnaire shall be used for every recipient receiving training. The contractor shall include the results of the effectiveness evaluation in the training report, which is required in the Performance Work Statement for the contract.

(f) The coders, auditors and trainers should be working independently within 30 days of completion of formal training (CHCS/AHLTA/MHS Coding Guidelines/Command Orientation). New training requirements should have minimal impact on the contract employee’s performance. Examples of new training requirements include but are not limited to: IM/IT systems, software or hardware; new MHS coding guidelines; new interpretations of existing codes.