The document discusses creating a compliance culture in healthcare organizations by focusing on clinical documentation and medical coding. It emphasizes establishing a culture where stakeholders view compliance as an opportunity rather than a threat. This involves using HIPAA, CMS, and AHIMA standards to drive improved patient outcomes, team effectiveness, and reimbursements. Key areas of focus are medical necessity of care, risks of electronic health record documentation, and need for complete clinical documentation to justify codes and payments. The first steps outlined are aligning goals, identifying opportunities, and securing executive support for a multidisciplinary team to implement changes.

1. Creating a Compliance Culture
Using HIM compliance to Improve Patient
Outcomes, Increase Team Effectiveness, and
Maximize Payor Reimbursements
ProMedCode
Presented by:

2. Creating a Compliance Culture
Mention the term “compliance” —
especially in the context of clinical
documentation and medical coding —
and your thoughts are likely to turn to
stifling regulations, less flexibility, lower
reimbursements and the specter of time
consuming, costly audits.
Instead of fearing HIM compliance,
healthcare organizations should use
well-established HIPAA, CMS
standards to help drive three operational
imperatives.
To be clear, the keys to success won’t be
found in enforcement… but rather in
establishing a culture that permeates
your organization and empowers
stakeholders to fundamentally change
their orientation on compliance from
“threat” to “opportunity.”
PROMEDCODE // PAGE 2

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1. MEDICAL NECESSITY
According to an OIG study published in May 2014,
fifty-five percent of claims for E/M services were
incorrectly coded and/or lacking documentation in
2010, resulting in $6.7 billion in improper Medicare
payments. The report went on to say:
“E/M services must be medically
reasonable and necessary, in addition to
meeting the individual requirements of the
CPT code that is used on the claim.”
Physicians’ documentation must support the
medical necessity and appropriateness, as well as
the level, of the E/M service.
2. EHR DOCUMENTATION RISKS
During a CMS-ONC session on Coding and Billing,
held in May of 2013, AHIMA presented “Developing
Standards for Coding with EHRs.” The downside
of “risky” EHR Documentation Features were
outlined:
• Inaccurate, outdated, or misleading
information
• Invalid auto-population of data fields
• Duplicated or erroneous information
• Inability to accurately support or defend
E/M codes
• “Smart phrases” that pull in identical data
elements (not specific to patient or
encounter)
3. CLINICAL DOCUMENTATION
OIG states clear and concise medical record
documentation is required for physicians to
receive accurate and timely payment for furnished
services. Encounter documentation should
include the care a patient received and pertinent
facts, findings, and observations about the
patient’s health history.
AHIMA’s Standards for Ethical Coding support the
requirement for complete and valid clinical
documentation:
“Assign and report only codes that are
clearly and consistently supported by by
authenticated clinical documentation in
accordance with applicable code set and
abstraction conventions, rules, and
guidelines.”
Current Regulatory and Standards Landscape
Three key issues are being closely scrutinized by regulatory agencies and standards bodies:

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Opportunities for Improvement
1. MEDICAL NECESSITY
Medical Necessity is lens through which
all individual patient encounters must be
managed.
2. ELECTRONIC HEALTH RECORDS
EHR templates and workflows aid in clinical
documentation, but cannot be used in a
manner that violates medical necessity or
compromises clinical documentation
EHR Templates
and Workflows
3. CLINICAL DOCUMENTATION
Complete and Valid Clinic Documentation is
the foundation upon which accurate
Procedural and Diagnostic code are
translated and payor reimbursements are
justified.
Completeand
ValidClinical
Documentation

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CLINICAL
QUALITY
MEASURES
COMPLIANCE
REVENUE
CYCLE
MANAGEMENT
Audits
Penalties
Clawbacks
PQRS
Patient
Safety
Indicators
Health
Grades
Quality
Scores
Complete and
Valid Clinical
Documentation
WRVUs
HCCs
RAF
Scores
Denials
Appeals
Population
Health
Mngmt Accurate
Health
Status
Care
Coordination
PATIENT
CARE Team
Effectiveness
Scope of Impact
Clinical Documentation, based on
Medical Necessity, is the foundation upon
which E/M codes are translated. The
accuracy of these codes has far-reaching
implications, especially if you participate
in a health information exchange or
accountable care organization.
A/R Aging

6. Creating a Compliance Culture
Mention the term “compliance” —
especially in the context of clinical
documentation and medical coding —
and your thoughts are likely to turn to
stifling regulations, less flexibility, lower
reimbursements and the specter of time
consuming, costly audits.
Instead, healthcare organizations should
use HIM compliance and well-
established HIPAA, CMS and AHIMA
standards to help drive three operational
imperatives.
The key to success won’t be found in
enforcement… but in establishing a
culture that permeates your organization
and empowers all stakeholders to
fundamentally change their orientation
on compliance from “threat” to
“opportunity.”
“Management is doing things right.
Leadership is doing the right things.”
— Peter F. Drucker
© 2014 PROMEDCODE // PAGE 2PROMEDCODE // PAGE 6
Creating a Compliance Culture:
Initial Steps
Any cultural shift begins and ends with
alignment. Keeping this in mind, start with
the following initial steps:
• Align goals with operational imperatives
• Identify opportunities for improvement
• Secure executive sponsorship for
support, funding, resources
• Organize a multidisciplinary team
• Develop a comprehensive project plan
• Prioritize deliverables based on effort
and ROI
• Execute, learn, adapt