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,...

For peer review, try the audit form published by FPM at http://Stay educated. Opportunities include coding and compliance educational courses, and Web-based courses from CMS available online at http://cms.meridianksi.com/kc/main/kc_frame.
Conclusion

Some health care providers and insurance companies are forming regional information networks to share electronic medical records. Their reasoning for setting up these data banks is to help with the reduction of paperwork, help with billing, identify the most cost-effective treatment, and to fight against false claims. A person's medical information would be immediately available for the attending doctor. Therefore if an individual was injured in another part of the country, the attending physicians would have the patient's entire medical history at their fingertips. Included in this information could be life saving information that would be invaluable to the attending doctor. The creation of a large database would also allow researchers to track certain diseases as well as to patients' responses to certain drugs. This information could be valuable to drug companies for research purposes only. The creation of these databases would allow for better organization and more legibility of medical files. Since elaborate security systems can be developed to monitor these medical databases, electronic records may actually be more secure than paper records. Anyone can steal and/or fax a copy of a paper record without leaving a trace.