PAGE: 1 of 3 / REPLACES POLICY DATED: 5/97, 9/2/98, 8/1/00, 6/30/02, 3/1/04 (HIM.COD.008), 3/6/06, 2/1/08, 1/24/09, 1/1/11, 1/1/12, 4/12/12, 5/30/12, 4/15/13
EFFECTIVE DATE: RETIRED 9/9/2015 / REFERENCE NUMBER: REGS.COD.008
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: Employees responsible for performing, supervising or monitoring coding of hospital inpatient and hospital outpatient services, including, but not limited to, employees in the following departments:
AdministrationEmergency Department
Registration/Admitting/SchedulingFacility Health Information Management
Radiology DepartmentAncillary Departments
Ethics & Compliance OfficersCorporate Regulatory Compliance Support
Laboratory DepartmentCase Management/Quality Resource Management
Human ResourcesPatient Access
HIM SharedService Centers (HSC)
PURPOSE: To ensure that onlythe approved HCA Incentive Pay Criteriafor Coding are used for any employeeinvolved in the performance or management of hospital coding processes and their incentive plan is tied in all or in part to coding performance. Implementation of an approved coding incentive plan is voluntary; however, if a plan is implemented then it must be done pursuant to this policy.
DEFINITIONS:
Prebill Review – The process whereby a coding review is performed by the designated person (i.e., Coding Manager/Supervisor) prior to the bill being released to ensure the ICD-9-CM and/or CPT codes, MS-DRG, or APCs assigned are supported by the medical record documentation.
New Hire –for purposes of this policy, means any newly hired individual, or any individual who previously worked for a Company-affiliated facility but has not worked as an employee or contractor for the Company-affiliated facility within the 90 calendar days preceding hire.
Focus Review -The process whereby a coding review is performed by the designated person (i.e., Coding Manager/Supervisor) on a determined set of ICD-9-CM codes and/or MS-DRGs or ICD-9-CM/CPT and/or APCs to ensure the ICD-9-CM and/or CPT codes, MS-DRG, or APCs assigned are supported by the medical record documentation.
Random Review – The process whereby a coding review is performed by the designated person (i.e., Coding Manager/Supervisor) on a random sample of medical records to validate ICD-9-CM codes and/or MS-DRGs or ICD-9-CM/CPT and/or APCs to ensure the ICD-9-CM and/or CPT codes, MS-DRG, or APCs assigned are supported by the medical record documentation.
External Vendor Review – The process whereby a facility/HSC request a coding review to be performed by an external vendor (i.e., HIA) to ensure that the ICD-9-CM and/or CPT codes, MS-DRG, or APCs assigned are supported by the medical record documentation.
POLICY: The HCA Incentive Pay Criteria for Coding are the ONLY acceptablecriteria that can beusedfor employees responsible for performing, supervising or monitoring hospital coding of inpatient and outpatient services if an incentive plan related to coding performance, in all or in part, is implemented. Lump sum payments or other incentive pay plans for non-codingrelated special projects or functions are acceptable such asmeeting education expectations, survey results, budget management, employee turnover, employee engagement, clean-up projects and employment/sign-on.
PROCEDURE:
- The approved and only acceptable HCA incentive pay criteria for coding are documented in the Attachment to this policy. Employees on Performance Improvement Plans (PIP) are not eligible for additional compensation plans.
- The HCA Incentive Pay Criteria for Coding are the ONLYcriteria that may be implemented for any Company employee involved in the performance or management of hospital coding processes and some or all of their incentive pay is based on coding performance, with exception as noted within the plan.
- If anHSC/facility has a coding related incentive or bonus pay plan that uses criteria different than the approved criteria in Attachment A, then:
- Thenon-approved coding incentive and bonus pay plan must be terminated immediately and reported to the HSC/facility CFO and ECO.
- Current coding incentive and bonus pay plans must be reviewed with the HSC/facility CFO to determine an immediate and appropriate coder compensation transition plan and/or transition to the approved coding incentive criteria.
- Consult the HSC/facility Human Resources Department for advice on coder compensation plans and/or implementation of the approved coding incentive criteria.
- The Corporate Regulatory Compliance Support (Regs) and Parallon Business Performance Group will provide oversight to the HCA Incentive Pay Criteriafor Coding. The HSC/facility HIM departments are responsible for implementation and monitoring of the HCA Incentive Pay Criteriafor Coding.
b.HSC/facility HIM Management is responsible and accountable for ensuring all documents and calculations are valid,accurate and retrievable.
c.Employees who have questions about a decision based on this policyor wish to discuss an activity observed related to application of this policyshould discuss these situations with their immediate supervisor to resolve the situation.
d.All day-to-day operational issues should be handled locally; however, if confidential advice is needed or an employee wishes to report an activity that conflicts with this plan and is not comfortable speaking with the supervisor, employees may call the toll-free Ethics Line at 1-800-455-1996.
e.For any questions regarding this policy, please contact the HIM Operations Communications mailbox or RegsHelpline via Outlook.
REFERENCES:
- Coding Documentation for Inpatient Services Policy, REGS.COD.001
- Coding Documentation for Outpatient Services Policy, REGS.COD.002
- Query Documentation for Clinical Documentation Improvement (CDI) & Coding – Compliance Requirements Policy, REGS.DOC.002
- Inpatient and Outpatient Coding Compliance Monitoring and Auditing Policy, REGS.COD.018
- Records Management Policy, EC.014 (applies to all clinical and business records)
- Health Information Management Productivity Guidelines (By Function)
- Coding Quality Control & Benchmark Analysis Manual
- CPCS Abstract Module Compiled Reports
9/2015
Attachment to REGS.COD.008
HCA Incentive Pay Criteria for Coding
Purpose
To ensure that the HCA Incentive Pay Criteriafor Coding is used in any incentive plans for any Company employee involved in the performance or management of coding processes if said incentive plan is related to performance. The implementation of the incentive plan using coding criteria is voluntary; however, if the plan is implemented then compliance with the outlined process is mandatory.
Scope
Any HSC or HIM personnel directly involved with the function of coding or the management of coding whose incentive plan is based in whole or in part on coding performance. Examples include:
- Coding Management (e.g., HSC/Facility Coding Director, HIM Director, HSC/Facility Coding Manager, Coding Supervisor, and HSC Coding Leads).
- Coding Staff (e.g., HCA (including Parallon Business Performance Group) full-time and part-time acute care inpatient, outpatient, inpatient/outpatient Coders, Parallon Business Performance Group “Pool” Coders, and Parallon Business Performance Group Coding Quality Reviewers).
- HSC Coding Management can either participate in the HCA Incentive Pay Plan for Coding or the HSC Incentive Plan but not both.
Eligibility
Coding Management
- Employees are employed at the HSC/facility/Parallon Business Performance Group at the time of pay out
- Employees with no formal disciplinary actions during the incentive period
Parallon Business Performance Group Coding Quality Reviewers
- Coding Quality Reviewers who are employed with the Parallon Business Performance Group at the time of pay out
- Coding Quality Reviewers with no formal disciplinary actions during the incentive period
Coding Staff/Coding Pool
Coders who are employed at the HSC/facility/ Parallon Business Performance Group at the time of pay out
Coders who have had no formal disciplinary actions during the incentive period
PRN coders must have worked at least 35 hours in the applicable incentive quarter to be eligible
Coding Management and staff must have been employed and working in the correlating roles 6 months prior to the quarter included in the incentive.
Criteria
In order to ensure a balanced approach of quality and quantity, the coding incentive plan may NOT include the following indicators:
- Case mix,
- Base case mix,
- Percentage of major surgery,
- Medicare Focus List I, II, or III percentages or volumes,
- Complication and comorbidity (CC) percentage,
- MS-DRG/APC percentages or volumes,
- Days from discharge to bill.
- Accounts Receivable Days/Dollars, or
- Other coding indicators that are impacted by factors beyond complete, accurate and consistent coding(e.g., Core Measures,Hospital Acquired Conditions (HAC), State Reporting initiatives, etc.).
Only the following criteria may be used in incentive plans for coding performance:
- Non-coding criteria (e.g., employee engagement, employee turnover, budget, cost per stat), excluding the prohibited items listed above, may be used and/or,
- Coding Education, and
- Coding Quality, and
- Coding Productivity.
The specific criteria for education, quality and productivity are as follows:
Coding Management
- All staff ‘tagged’ as coders (including themselves and PRN coders) as applicable (i.e., in the manager’s span of control) who have performed and met all educational requirements per REGS.COD.006. The education incentive criteria may not exceed 5% of the total incentive plan amount.
- Productivity for the entire non-PRN coding staff and PRN coding staff that worked over 160 hours annually met or exceeded the facility’s predetermined overall productivity standard. The corresponding productivity incentive percentage may only be received if the coding quality incentive metric was achieved. The incentive percentage for productivity must be equal to or lower than the percentage for coding quality.
- Results of all internal/external coding quality reviews must be at 95% or greater.
- Internal reviews -Internal (random and focus) reviews include coding quality reviews performed by HSC/Facility Coding Director, HIM Director, HSC/Facility Coding Manager, Coding Supervisor, HSC/Facility Coding Leads, Parallon Business Performance Group Coding Quality Reviewers and Internal Audit.
- External reviews - External reviews include allcoding reviews performed by a credentialed coder such asRAC, OIG, CERT, MIC, etc. if the denominator can be obtained (meaning it is known how many total records were reviewed for coding quality). Efforts should be made to obtain the initial request letter along with the determination (findings) from the external reviewer. Final review outcomes must be included for discharges within the incentive calendar year (or applicable quarters if prorated) for which the employee managed the coding processes.
The corresponding quality incentive percentage must be equal to or greater than the percentage for coding productivity.
Coding Quality Reviewers
- Coding Quality Reviewer has met all educational requirements per REGS.COD.006. The education incentive criteria may not exceed 5% of the total incentive plan amount.
- The Coding Quality Reviewer met or achieved productivity. The corresponding incentive percentage for productivity may only be received if the coding quality incentive metric was achieved. The incentive percentage for productivity must be equal to or lower than the percentage for coding quality.
- The Coding Quality Reviewer must have achieved an accuracy rate of 95% or greater based on internal coding quality reviews. The corresponding quality incentive percentage must be equal to or greater than the percentage for coding productivity.
Coding Staff/Coding Pool Staff
- Coder/Coding Pool Coder has met all educational requirements per REGS.COD.006. The education incentive criteria may not exceed 5% of the total incentive plan amount.
- The Coder/Coding Pool Coder met or achieved productivity. The corresponding incentive percentage for productivity may only be received if the coding quality incentive metric was achieved. The incentive percentage for productivity must be equal to or lower than the percentage for coding quality.
- The Coder/Coding Pool Coder must have achieved an accuracy rate of 95% or greater based on internal coding quality reviewsor for HSC/Pool coders there must be no more than 1 MS-DRG error in the quarter for random reviews. The corresponding quality incentive percentage must be equal to or greater than the percentage for coding productivity.
Procedure
Incentive compensation amounts for coders, coding pool, coding quality reviewers and coding management will be determined based on the HSC’s/facility’s budget. Incentive is paid out quarterly for coders and annually for coding quality reviewers and coding management. The following options need to be determined for budget approval prior to the quarteror year the incentive plan is implemented:
- Quarterly/annual percentage of annual salary or predetermined payment amount
- Incentive approach
- Tiered; or
- Non-tiered
Example of tiered quality incentive criteria:
Accuracy Rate / Eligible Incentive95.00% / Ineligible
95.00% – 97.00% / X% or $X
97.01% - 98.00% / X+% or $X+
98.01% - 100% / X++% or $X++
Example of non-tiered quality incentive criteria:
Accuracy Rate / Eligible Incentive95.00% / Ineligible
95.00% / X% or $X
Examples of partial incentive:
Accuracy Rate(Incentive Percentage 50%) / Productivity Rate
(Incentive Percentage 45%) / REGS.COD.006 (Incentive Percentage 5%) / Eligible Incentive
95.00% / 95.00% / In compliance / Partial eligibility- 5%
95.00% / 95.00% / In compliance / Partial eligibility- 55%
95.00% / 95.00% / Non-compliance / Partial eligibility-95%
Productivity Rate
In order to incorporate individual coder productivity measures into an incentive pay plan, the facility/HSC mustadhere to predetermined productivity standards as established by the facility/HSC. It is recognized that the patient type specific productivity standards may be different for varying circumstances (e.g., new hires, coders newly migrated to an HSC, coding needing to access the medical record across disparate systems, coders coding for large numbers of facilities).
MS-DRG/Overall Outpatient Accuracy Rate
Internal coding quality control monitoring must be performed on a quarterly basis using a random sample for each coder. It must be a true random sample as described in the Random Inpatient/Outpatient Record Selection section below. The quarterly reviews are to be performed retrospectively on at least 30 inpatient records for inpatient coders; 30 inpatient and 30 outpatient records for inpatient/outpatient coders; or 30 outpatient records for outpatient coders for the facility environment, and on at least 18 records for inpatient coders, inpatient/outpatient coders or outpatient coders for the HSC environment. The inpatient accuracy rate will be based on MS-DRG validation. The outpatient accuracy rate will be based on a combined accuracy rate.
Inpatient
All inpatient types are included.
In addition to MS-DRGvalidation, the following items must be reviewed (will not impact incentive eligibility):
Sex
Age
Patient Status Code
Birth weight for neonates
Patient Type (IP vs. OP)
Admit/Discharge Date
Outpatient
Outpatient types include:
Observation (INo)
Surgical Day Care (SDC)
Emergency Department (ER)
Clinical (CLI)
Recurring (RCR)
If HIM coding staff is responsible for assigning Evaluation and Management (E&M) codes for any patient type, these codes must be validated in the process of reviewing applicable records.
Outpatient records will be reviewed based on the accurate assignment of:
CPT code(s)
ICD-9-CM codes
Modifiers
E&M assignment
Who Performs HSC/Facility Based Reviews
Reviews must be performed by HCA/Parallon Business Performance Group HIM/Coding staff (e.g., HSC Coding Director, HIM Director, Coding Manager, Coding Supervisor, Coding Quality Reviewer, Lead Coder) who has met all mandatory educational requirements as outlined in Company policies REGS.COD.005, REGS.COD.006, or by a Certified External Coding Vendor (refer to REGS.COD.011). Internal Audit will perform the coding quality reviews for the Coding Quality Reviewers on anannual basis.
Random Inpatient/Outpatient Record Selection Process
For the facility environment, a report should be compiled in MEDITECH Abstracting Statistical Reports. Ensure the correct discharge date or service date range is selected for the quarter and abstract status is Final. All payers are to be included. For example, if the facility is conducting QC for the first quarter of the year, select date ranges of 1/1/xx through 3/31/xx. The report should be ‘Major’ sorted by coder. ‘Minor’ sort the report by MEDITECH patient status.
In order to obtain patient level information, the report must be printed from Patient Reports in Abstracting. For more information on complied reports, please refer to the CPCS document on Atlas:
Once the Patient Report is printed, record selection for each coder must include every 5th record for each patient type until the minimum review volume is achieved. For example, Coder A is an IP/OP coder which codes inpatient and SDC records. For inpatient record selection, you will select every 5th record on the report totaling 30 for inpatient. For SDCs record selection, you will select every 5th record on the report totaling 30 records for SDCs. A total of 60 records would be reviewed for Coder A.
If a patient type’s total volume for the quarter does not equal 30 records following the random selection process of every 5th record, the process shall be repeated applying the selection of every 6th record until the minimum review volume is achieved.[1] If the total volume for a patient type by coder is 30 or less, then 100% of the records must be reviewed. If a facility chooses to routinely review volumes beyond the minimum requirements the same volume must be reviewed for all coders to ensure equity. In addition, the same random sampling methodology must be used to select the records.
For the HSC environment, RAT-STATs will be used to randomly select 6 charts per month/18 records for the quarter for each coder/pool coder. Ensure the correct discharge date or service date range is selected for the month/quarter. All payers are to be included and all facilities a coder coded for must be included in the population. For example, if the HSC is conducting QC for the first quarter of the year, select date ranges of 1/1/xx through 3/31/xx.