Lynn Thornton, RHIA, CCS
The health information industry is packed with opportunities for those professionals willing to work hard to expand their skills. I’ve created my own opportunities in the health information management world by becoming a subject matter expert (SME) in regulatory concepts. This is not a self-appointed title; it is one that has been bestowed upon me by various HIM Directors, Managers and CFOs. This skill set has set me apart from coders with the same level of expertise I have, and, it has made me seem like a more valuable staff member and/or consultant.
The best part about this story is this knowledge and competency is free to anyone who seeks to attain it. If I could change anything about our education for new coders, or ongoing education in the hospital setting it would be to include strong education in these regulatory concepts. This education should be part of the post audit process during which the coder learns not only coding concepts they were deficient in, but also the background regulatory knowledge’s and competencies to work through denied claims.
Listed below are some of the resources I use in the denials management process. As an auditor and coding educator I use these and many more reference materials in conducting research and providing coding guidance. Coders may use this brief information as a start toward regulatory competency.
Ideally, all edits will be resolve prior to the coder concluding their work on an encounter. Additionally, clicking “compute” on the encoder does not complete the claim. If an edit is present, the entire claim sits open in the business office pending edit resolution. It is best practice for any claims with unresolved edits be returned to the coder for resolution. It is those very claims which may sit unresolved and finally hit the timely filing deadlines.
All coders, whether inpatient and/or outpatient should be skilled in researching the National Coverage Determinations and/or Local Coverage Determinations when called upon to do so. These coverage determinations may be applicable to both inpatient and outpatient services. Medicare provides an educational document intended to assist users in working through accessing and interpreting the information on this resource. The following information is available to assist in this endeavor.
The CMS Medicare Physician Fee Schedule (CMS MPFS) is a critical resource for coding in hospitals and physician offices. Coders should use this resource to determine the work relative value unit (wRVU), multiple procedure indicators, bilateral surgery indicators, assistant surgeon indicators and much more.
I love regulatory research. It is my pleasure to assist facilities in claim denial resolution, however, best practice is for a coder to become proficient in this area themselves-it just takes a little time and effort. Time and effort well spent!