*Nurse documentation and diagnosis coding
*Injured staff and EMTALA

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The OIG Work Plan for Fiscal Year 2003

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Compliance Hot Topics: Billing and Coding, EMTALA, Stark, HIPAA

Question of the Week

Welcome to Compliance Monitor Q&A.

Our mission is to answer your difficult compliance questions-and your simple ones, too. To submit a question, send it to Compliance Monitor Q & A editor Kate Alvarez at kalvarez@hcpro.com. We hope you enjoy this service and we welcome your feedback.

This week's questions

• Nurse documentation and diagnosis coding
• Injured staff and EMTALA

• Pay-Per-View article: The cost of compliance

• How does your organization handle patient financial issues?

Q: "When you assign codes for lab tests or x-rays, can you code a symptom from the nurse's notes that meets medical necessity requirements? Is it acceptable to code a diagnosis from a medication record, like an emergency room record, that only lists the name of the medicine?"

A: Numerous publications on coding guidelines, like the American Hospital Association's Coding Clinic, say time after time that physician documentation should support all diagnosis coding. When a coder is uncertain whether to assign a code, they should query the physician/provider, not a nurse (nurse midwives being the exception). Sections of the medical record that may be used for coding documentation include, but are not limited to, the history and physical (H&P), the discharge summary, operative report, and physician progress notes. Documentation supporting code assignments should only be physician based and should not include nursing documentation.

When a physician, physician assistant, or nurse practitioner orders a diagnostic test/procedure, it's the provider's responsibility to supply a reason for the order(s). Coding from a medication list cannot assure the use of the medications was the reason behind the test order.

Facilities should work with their medical staff to develop specified coding guidelines. The Coding Clinic states, in the 2000 first quarter publication: "These facility guidelines must not conflict with the 'Official ICD-9-CM Guidelines for coding and reporting' developed by the cooperating parties and, additionally, they should not be developed to replace the physician documentation needed to support code assignment."

This question answered by Pam Farmer, Manager of Diagnostic Services Support at NorthEast Medical Center in North Carolina.

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WE NEED YOUR EXPERTISE!

Join the Compliance Monitor Team! Compliance Monitor Q&A relies upon experts just like you to answer pressing compliance questions. We're looking for experts in coding, billing, documentation, HIPAA, EMTALA, Stark, laboratories, and many other areas of compliance.

If you are interested in answering questions from your peers, please e-mail Compliance Monitor editor Kate Alvarez.

Tips, examples, and recommendations for planning your compliance focus areas and audit topics for the coming year

HCPro can help you use the 2004 Work Plan to your best advantage. Attend the 90-minute live audioconference, "2004 OIG Initiatives: How to Get Ready and Stay in Compliance." Here is what Andy Navarro, Legal Counsel at Trinity Mother Frances Hospital in Tyler, TX, had to say about last year's HCPro program on the 2003 Work Plan for Hospitals:

"Excellent program! This is a must for compliance professionals!"

This program will be held on 12/10/2003. To register, or learn more, click here or call 800/650-6787 and mention source code EZ23867H.

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Click here to take our quick survey on your financial policies and procedures.

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To find out more about what happened to this NJ hospital system, order the pay-per-view article " The cost of compliance." The cost is $10. Subscribers to the online version of Strategies for Health Care Compliance have free access to this article. Subscribers to the print edition can find it in their December issues.

A $30 steal.
You can read this article and much more in the December issue of Strategies for Health Care Compliance. Your cost: Five stories for only $30. You'll also learn what to do if you have a qui tam relator, solutions for drafting Stark compliant physician contracts, how to develop a financial policy, and how to avoid four common security pitfalls to help your facility rein in technology spending.

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HERE'S THE TOOL YOU NEED NOW TO PREPARE FOR MEDICARE REFORM

The Medicare reform legislation is going to radically affect every health care organization. Make sure you understand exactly how it will change your life with the easy-to-use "Medicare Reform Act Analysis and Explanation."

This book, CD-ROM, and Special Report set puts the 700-page bill at your fingertips in an organized binder and searchable CD-ROM so you can find everything you need to know quickly and easily. You'll also receive a Special Report that provides stories designed to help different health care workers understand how the new bill will affect their jobs.

To order or learn more, call HCPro Customer Service at 800/650-6787 and mention source code EB24678A.

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A: To read the answer to this question, click here.

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To submit your answer, go to the Question of the Week at Complianceinfo.com.

Here are the answers to the last survey:

When will your organization begin auditing its HIPAA compliance program?

• Within the next six months: 68%
• In 7 to 12 months: 17%
• In 12+ months: 9%
• We do not plan to audit: 6%

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Network with your audit colleagues

"Audit Talk" is a new, moderated chat forum that members can use to post messages or questions for their peers 24-hours-a-day. "Audit Talk" offers a free forum to network, share ideas, and solve problems for those in the audit industry. Getting involved is easy. To subscribe, just send your request to this e-mail: owner-audit_talk@hcpro.com.

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Send your comments and questions about Compliance Monitor Q&A to:

Kate Alvarez
Editorial Assistant
kalvarez@hcpro.com