Addition or loss of a specialty physician(s) to the medical staff
Changes in coding practices or guidelines
However, significant and unexplained variations in the CMI
may be an indicator of coding variances and therefore should
DRG reconciliation and CMI tracking should be concomitant compliance processes. Effective DRG reconciliation processes may result in appropriate changes to the CMI while a
CMI variance may indicate a need for more robust DRG review.
Auditing and Monitoring Necessary to Maintain
An inpatient coding compliance plan must include auditing
and monitoring of the inpatient coding staff. Ongoing coding
quality reviews are necessary to maintain a high level of accuracy, ultimately resulting in billing accuracy. Considerations in
developing coding auditing and monitoring processes include:
Utilize Medical Provider Analysis and Review (MEDPAR)
data or other national data to determine differences between an organization’s billed data and the national average. 2 Identified variations may or may not indicate potential fraudulent or abusive coding and billing practices.
However, variations require further analysis to determine
if there is a compliance issue.
Organizations should monitor those areas under investi-
Have a Corrective Action Plan
gation by government payers and other external entities.
- CC/MCC capture rates
- Single CC/MCC cases
- High-risk DRGs, such as Sepsis, Acute Respiratory Fail-
ure, and Encephalopathy
- Clinical or DRG denials
- Changes in CMI
Inpatient coding audits can be performed on cases selected
at random or more intentionally. Sampling approaches in-
clude, for example, random samples of specific record types or
identified coders, focused samples of specific codes, or statis-
tically valid random samples with and without stratification.
The inpatient coding compliance program should provide
guidance to determine the appropriate sampling methodol-
ogy to accomplish the goals of a specific audit effort.
A corrective action plan is a necessary part of any inpatient
coding compliance program. Design corrective actions to prevent reoccurrence of the same problem in the future. Corrective actions often include updated policies and procedures as
well as staff education to ensure a thorough understanding of
the appropriate coding practice.
The compliance officer should investigate any potential cod-
Keep Up with Annual Updates
ing fraud or abuse issue. The investigation should include in-
terviews with coding staff, coding management staff, and any
others directly involved. The investigation should also include
review of policies, coded data, and any related previous educa-
tion provided. The purpose of the investigation is to identify
the underlying cause of the coding issue, the extent of the im-
pact, and ultimately determine if there is truly a compliance
issue versus an error, for example.
Review and update the inpatient coding compliance program at
least annually. As previously noted, inpatient compliance should
address areas under investigation, which are constantly changing. For example, in 2017 the OIG transitioned to a web-based
work plan that is regularly updated. The annual work plan covers
projects performed under the supervision of the OIG by the Office
of Audit Services, the Office of Evaluation and Inspections, the
Office of Investigations, and the Office of Counsel to the Inspector General. Each of these agencies assists in the development of
the OIG’s work plan. Their actions, related to the work plan, include audit, inspection, investigation, and litigation.
Update inpatient coding compliance efforts at least annually to
align with industry trends in coding compliance, including OIG
priorities. For example, since December 2018, the OIG Work Plan
has included an explanation of the OIG’s intent to assess inpatient
hospital billing for Medicare beneficiaries. The plan describes a
two-part study. The first part gathers “landscape information
about hospital billing, and how it has changed over time.” The
second part will use the information to “target certain hospitals
or codes to look for patterns of incorrect coding or billing.” 3
A robust inpatient coding compliance program should include
the essential components described in this article at a minimum
and should be regularly updated to ensure all aspects are current
and adequate to maintain inpatient coding compliance. ¢
1. Land, Daniel et al. “Components of an Effective Outpatient Coding Compliance Policy Program.” Journal of
AHIMA 90, no. 1 (January 2019): 38-39.
2. Centers for Medicare and Medicaid Services. “MEDPAR
Limited Data Set (LDS) – Hospital (National).” January
7, 2019. www.cms.gov/research-statistics-data-and-sys-tems/files-for-order/limiteddatasets/medparldshospi-talnational.html.
3. Office of Inspector General. Work Plan. https://oig.hhs.
Kravtsova, Marina. “Discussing Second Level Reviews in
CDI.” Journal of AHIMA website. September 29, 2017.
Schraffenberger, Lou Ann and Lynn Kuehn. Effective Management
of Coding Services. Chicago, IL: AHIMA Press, 2011.
Kathryn DeVault ( firstname.lastname@example.org) is manager of HIM
consulting services and Mary H. Stanfill ( email@example.com) is
vice president of consulting services at United Audit Systems, Inc.