Back to top

The Importance of Compliance

Coding Corner

The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.

The Importance of Compliance
Compliance is conformity in fulfilling official requirements. The “why” of compliance is a question frequently asked by physicians. Why do we have to do this? The simple answer is, because you have to. On several levels there are “rules” of compliance that include documentation issues and assignment of codes with specificity.

The 1995 and 1997 Evaluation and Management (E&M) guidelines that all insurance carriers utilize state, “the importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.” ICD-9 diagnostic coding guidelines state that, “adherence to these guidelines when assigning ICD-9-CM diagnosis and procedure codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”

As a practicing physician you are inherently obligated to follow the rules of documentation, coding and billing. These are regulations that have been established by the Centers for Medicare and Medicaid Services (CMS), HIPAA (and other governmental acts) and insurance carriers.

Document all the work you do, code with specificity based on the documentation, submit a claim for that work and receive payment. Compliance has a role in each step. Future Coping with Coding segments will present more details.