The importance of uniform terminology, coding and standardization of the data
Uniform terminology, coding, and standardized data entry protocols are necessary for assuring accurate information retrieval. The health informatics componentss need to be using compliance plan in place. Here are some guidelines for assurring the acurracy of terminology, coding, and data entry.
Conduct internal monitoring through periodic chart audits
Develop written coding and documentation standards and procedures, and implement them;
Designate one of your staff members as a compliance of-cer to monitor your practice's compliance
Respond appropriately to potential violations by investigating and disclosing them, as• Develop open lines of communication by discussing at staff meetings how to avoid erroneous or fraudulent conduct or by using a community bulletin board to keep employees
Develop a CPT utilization report. Separate your Medicare patients from your otherpatients for a more appropriate analysis. A useful template is available online at http://www.aafp.org/fpm/20020700/codingfrequencycomparison.xls.
Compare your practice to benchmarks. For Medicare, see CMS 2002 data online at http://www.aafp.org/fpm/20040600/20arey.html#box_a.For commercial claims, see MGMA2003 survey results at http://www.aafp.org/fpm/20040600/20arey.html#box_b
Be prepared to explain the coding variances. Ask yourself questions such as the following: Were the services medically necessary? What was the clinical judgment used to treat thepatient's condition? Does the documentation support the E/M level billed?
Know your risk areas. The OIG has identi-ed some potential compliance risk areas for physician practices: coding and billing, documentation, and "reasonable" and "necessary"services. Find out which of these areas is your weakest, and take steps to improve.
Perform internal chart audits. You can use a peer-review process,...
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