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OIC Ed.1-19-18 1 Park Nicollet Health Services Required Education Manual This manual includes the following: Required education based on your role at Park Nicollet Health Services Required Education and Compliance Agreements Acknowledgement Form

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This manual includes the following:
Required education based on your role at Park Nicollet Health Services
Required Education and Compliance Agreements Acknowledgement Form
OIC Ed.1-19-18 2
Table of Contents
Head + Heart, Together: Our culture, our way, our mantra .............................................................................. 6
Required Education ............................................................................................................................................ 7
Orientation to our Code of Conduct, Privacy, Security and Compliance Program ............................................... 8
Code of Conduct .............................................................................................................................................. 8
Privacy and Confidentiality ............................................................................................................................... 8
Gifts, Entertainment, Favors and Meals ......................................................................................................... 10
Fraud Waste and Abuse (FWA) ...................................................................................................................... 10
Report concerns or violations of the Code of Conduct ................................................................................... 11
Emergency Management ................................................................................................................................. 12
Park Nicollet's Emergency Management Plan .............................................................................................. 13
Facility Alert: Fire .......................................................................................................................................... 13
Severe weather: What do you do? ............................................................................................................... 15
Threat Assessment and Response Protocol .................................................................................................. 16
Weapons policy ............................................................................................................................................. 17
Security Alert: Missing Person ...................................................................................................................... 18
The Hospital Incident Command System (HICS) ........................................................................................... 19
Harassment, Offensive and Disruptive Behavior, and Workplace Violence .................................................... 20
What is sexual harassment? ......................................................................................................................... 20
What about consensual relationships between coworkers at PNHS? .......................................................... 20
What is non-sexual harassment? .................................................................................................................. 20
What is not considered harassment? ........................................................................................................... 21
Disruptive behaviors ..................................................................................................................................... 21
Workplace violence ....................................................................................................................................... 21
OIC Ed.1-19-18 3
Who is covered by these policies? ................................................................................................................ 26
Reporting violations ...................................................................................................................................... 27
Advanced Corporate Compliance for the Patient Revenue Cycle ................................................................... 29
The Revenue Cycle Process ........................................................................................................................... 29
Registration, scheduling and check in ........................................................................................................... 29
Clinicians and coding ..................................................................................................................................... 31
Abuse, fraud, and auditing ............................................................................................................................ 37
You can make a difference ............................................................................................................................ 40
Hazardous Waste for Healthcare Workers ...................................................................................................... 41
Managing hazardous waste requirements ................................................................................................... 41
Why manage hazardous waste? ................................................................................................................... 41
Hazardous waste management resources .................................................................................................... 41
Infectious waste ............................................................................................................................................ 42
IV solutions (without medications) waste .................................................................................................... 43
P-listed pharmaceutical waste ...................................................................................................................... 44
Do NOT dispose of this waste in the black MEDS box .................................................................................. 44
What do I do with a dropped pill? ................................................................................................................ 45
General hazardous waste ............................................................................................................................. 45
Speak up ........................................................................................................................................................ 46
BEST Care Reporting ..................................................................................................................................... 51
What is 'Right to Know'? ............................................................................................................................... 51
Safety data sheet (SDS) ................................................................................................................................. 51
Container labeling ......................................................................................................................................... 52
OIC Ed.1-19-18 4
Product labels: Hazard and precautionary statements ................................................................................ 53
Harmful physical agents ................................................................................................................................ 53
What to do if splashed with a chemical ........................................................................................................ 54
Cytotoxic drugs ............................................................................................................................................. 54
Healthcare-acquired infections? ................................................................................................................... 55
Bloodborne pathogens ................................................................................................................................. 55
Tuberculosis (TB) ........................................................................................................................................... 55
Standard Precautions .................................................................................................................................... 56
Transmission-based precautions .................................................................................................................. 56
Workplace Violence Prevention....................................................................................................................... 60
OIC Ed.1-19-18 5
Welcome to Park Nicollet! At Park Nicollet, we never forget why we’re here. We believe outstanding healthcare is delivered when we
merge the science and intellect of medicine with the compassion, spirit and humanity of our hearts. We
refer to this as "Head + Heart, Together," and it exists to inspire constant improvement and lasting success.
We achieve this by partnering with patients and families in everything from care decisions to service and
facility design. As we work together as a unified team, we engage patients, families and the community, and
put them at the center of everything we do.
Mission – why we’re here
Improve health and well-being in partnership with our members, patients and community.
Vision – where we’re headed
Health as it could be, affordability as it must be, through relationships built on trust.
Values – what guides our actions
Excellence: we strive for the best results and always look for ways to improve.
Compassion: we care and show empathy and respect for each person.
Partnership: we are strongest when we work together and with those we serve.
Integrity: we are open and honest and keep our commitments.
We are committed to living our values. That means you can expect certain things from each of us.
You can expect us to be your partner and treat you with dignity and respect. You can expect us to listen carefully and give you good, timely information. You can expect us to do our best to provide affordable, coordinated, high-quality care and services that are easy to find and simple to use. You can expect safe, clean spaces. And we will do our very best to earn your trust by being open and honest, and keeping our word.
If we ever fail to live up to our values, please tell us so we can work to make it better.
Strategies – what we do
We approach our work and create our work plans by focusing on four dimensions.
People – Health – Experience - Stewardship
OIC Ed.1-19-18 6
Head + Heart, Together: Our culture, our way, our mantra Head + Heart, Together exists to inspire constant improvement together with patients, families, team
members and the community.
+ Heart (EQ) – Healing relationships with compassionate care (human, spiritual) Together – Engage with patients, families, teams and communities
Your responsibility
Head + Heart, Together defines and sets expectations for how we do our work and treat each other, our
patients and their families. By aligning our behavior to Head + Heart, Together, we strengthen the core of
our culture - putting patients and families at the center of everything we do.
OIC Ed.1-19-18 7
Required Education Park Nicollet Health Services (PNHS) must meet various regulatory agency guidelines for mandatory
education. On an annual basis, managers and supervisors are responsible for ensuring team members and
non-employees are provided training applicable to their job function.
Your required education is based on your role. Please identify your role on the table below and complete
the associated tasks.
Patient Care: Sections 1, 2, and 3
Section If your role is…. Task Page
1. Patient care or
Read required education:
Orientation to our Code of Conduct, Privacy, Security and Compliance program
Emergency Management
7
12
20
2. Patient care Additional required education for Patient Care roles:
Advanced Corporate Compliance for the Patient
Revenue Cycle
Patient Safety
29
41
46
51
4. Patient care or
Compliance Program
Code of Conduct
Among the most important commitments we make at our organization is the commitment to do the
right thing for our patients, members and the community. That's how we earn trust, impact the lives of
others and ultimately achieve our mission. Our culture of Head+Heart, Together is a strong foundation.
It, along with our values of Compassion, Excellence, Integrity and Partnership are the basis for our Code
of Conduct, which is an important guide to doing our work with integrity.
It’s your resource for finding answers to important questions and doing the right thing. It applies to
every person who represents us, including non-employees. You are expected to follow our Code of
Conduct. You have been provided with “Your guide to the Code of Conduct,” a resource brochure that
gives you general information about the Code of Conduct and useful resources to use if you have
questions or concerns.
Access or download the complete Code of Conduct from myPartner or Facets or from your
organization’s external website under the “About” or “About Us” section. Ask your leader if you need
help locating the Code of Conduct.
The material in this packet covers some of the topics most relevant to you as a non-employee.
Privacy and Confidentiality
As a non-employee, you will come into contact with confidential information. It may be related to our
business, our patients or our members. For example, the patient or member information you may see
might be related to patient/member name, diagnosis, demographic or family information. Any and all
patient or member information must remain confidential, which means:
Only access, use or share it if necessary to do an assigned task
Only access, use or share it at the time that it is needed to do an assigned task
Only access, use or share it to those who have a business, jobrelated need to know
Only access, use or share the minimum amount of information you need to do your assigned
task
Ask yourself: Do I have a business need to know? Do I need to access, use or share this information to do
my assigned task? If the answer is “no,” then don’t access, use or share the information.
If someone you know is a patient or member, it is important for you to separate your role as a non-
employee from your friend or family relationship. This means that you should not use the information
or the access that you have because of your role to snoop or give information to family members or
friends.
Never discuss patients or members with others unless it is part of your assigned task. Respect patient
and member privacy while you are at work and outside of work. This means you should not discuss
patients or members with other non-employees, volunteers, visitors or with family or friends, even after
your assignment ends.
If a patient or member asks about how to exercise their individual privacy rights (example: getting a copy of
OIC Ed.1-19-18 9
their record, or changing something in their record) talk to the supervisor in your area to get them the information they need. Review the Notice of Privacy Practices for more information on privacy rights.
Other sensitive information: You may learn business confidential information about our organization or the people who work here during your temporary assignment. You need to keep this information private as well and not use it for any outside purpose or personal use.
Some ways you can protect patient and member information:
Don’t talk about patients or member in public areas where others may overhear, such as
elevators, hallways or the cafeteria.
Don’t heave confidential, patient or member information on computer screens, printers, fax
machines or other places where people may see it.
Don’t take business, patient or member information outside of our work premises.
Properly dispose of information using the confidential destruction bins located throughout our
facilities when it is appropriate to dispose of it.
Access only the information that you are asked to work on.
Don’t give out patient or member information without proper authorization. Ask your
supervisor if you are unsure.
Make sure you have the right patient identified, and don’t share information until you’ve
confirmed ID according to the organization’s established policies and procedures
Never take a picture or make an audio recording of a patient.
Following all organizational policies and privacy standards. These are available on myPartner or
Facets.
A special note about the hospital directory: Sometimes patients ask for an additional level of privacy
protection during their hospital stay. They ask that their name NOT be included in the hospital directory.
You must respect this request. You must not reveal that this person is a patient in our facility. Not being
in the directory means that visitors who check at the admissions or information desks should NOT be
given any information about that patient, no callers should be transferred to the patient’s room and no
flowers or other items may be delivered to the room. Say, “I do not see this person in our directory.”
Answers are not always clear. Rules can’t always tell you what to do in every situation. If you have any
doubts or wish to report a concern, please contact the supervisor in your area or contact one of the
areas below:
Your leader
The Office of Integrity and Compliance [email protected]
The Integrity and Compliance Hotline 18664443493
Failure to comply with these rules and the Confidentiality of Patient/Member Information – Employee
Access and Use policy may be dismissed from the organization.
Information Security
Don’t open emails, attachments or links from unknown senders
Keep computers locked when stepping away
Do not leave mobile devices unattended or unlocked
Never email patient or member information except as necessary to perform an assigned task.
Never email patient or member information to or from a personal email account
Report suspected security incidents, suspicious activity, stolen/lost laptops and smartphones to the IS&T Support Center (9529677000) immediately
Use of Internet and Social Media
When using the internet, be aware of your surroundings, even if you are on break. Who can see
your screen? Think about the perception you are giving to patients or members in the area
Never post anything about patients or members on any social media, like Facebook or Twitter,
even if you don’t use their names and think you have removed all identifiers
We discourage “friending” or following patients or members whom you’ve met through your
assignment at Park Nicollet via social media
Make it clear that your opinions are your own when commenting on topics related to our
organization
Gifts, Entertainment, Favors and Meals
Our workforce, including our non-employees, must avoid the influence or appearance of
influence in our relationships with patients, members, patients and member’s family and
friends and vendors - companies that provide or want to provide supplies or services to our
organization.
You may not accept the following from patients, members, their family and friends or vendors:
o Gifts such as food, cash, discounts or gift cards, services or entertainment, including tickets to events, company swag (e.g. pens, pads of paper)
You may not participate in any activity that could potentially influence decisionmaking at work
If you have questions, talk to your supervisor; they will engage Human Resources and Integrity
and Compliance as necessary.
Fraud Waste and Abuse (FWA)
We are committed to preventing, detecting and correcting fraud, waste and abuse, which includes:
• Stealing (e.g., taking home excess supplies)
• Making false statements in documents about patients or members
• Identity fraud (Attempting to use a false identity or someone else’s name/date of birth/social
security number)
OIC Ed.1-19-18 1 1
If you’re aware of or suspect conduct that could be fraudulent, wasteful or abusive, report your
concerns immediately using one of the methods described below.
Report concerns or violations of the Code of Conduct
To your leader, or any leader
To the Human Resources team
To Integrity and Compliance
o [email protected]
o [email protected]
o Integrity and Compliance hotline: 18664443493 (you may be anonymous)
Emergency Management Park Nicollet's Emergency Management Plan ensures we continue to provide effective patient care when an emergency
affects our facilities. The goal of this section is to provide information for responding to situations that may affect the
health and safety of you, your coworkers, patients, and visitors.
Safety and Security Department and what to report
The Safety and Security Department serves to support a safe and secure environment in which our team members and
customers experience exceptional service.
What to report
All team members, regardless of the PNHS location at which they work, should report the following to Safety and
Security for support, response and/or reporting purposes:
Thefts or diversion of corporate or personal property
Suspicious people or events, unusual activity
Property damage or vandalism
Situations that could have an impact on personal safety or security to the facility, personal belongings, and
corporate resources and equipment
Harassment
Falls/injuries in work areas or public areas (at St Louis Park campuses)
Vehicle accidents or abandoned vehicles
How to report
To call in a report of an emergency event, please use the process below to assure an effective information exchange.
Methodist Hospital and
Ambulatory clinic and office locations
outside of St. Louis Park
Call 1-1-1
(local emergency responder)
Note: After, report event to PNHS Safety and Security at 952-
993-5101
• your name and call back number
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Security badge
Security badges (photo IDs) are used to verify that a team member, volunteer, or contractor has business in a PNHS
facility. These badges are your corporate name tag while working on PNHS properties. The Human Resources Personal
Appearance policy requires that all team members wear this visible identification while on duty.
Park Nicollet's Emergency Management Plan
Where to find emergency preparedness resources
The resources listed below are used throughout PHNS as emergency management guides.
Emergency Management Procedures Quick Reference
Locate it: Facets>Departments>Emergency Preparedness>Quick Clicks sidebar>Emergency Management
Procedures Quick Reference
Emergency Management Card
Obtain from your area leader or calling Safety and Security.
Emergency Quick Reference Guide
Utility Systems Failure Response Placard
Locate it: Facets>Departments>Real Estate>Quick Clicks sidebar>Utility Systems Failure Response
Facility Alert: Fire
Facility Alert: Fire is the PNHS emergency procedure enacted when there is evidence of a fire (smoke or flame). When a
Facility Alert: Fire is announced, follow the Fire Emergency Plan's 4-point procedure. Check with your area leader to
understand your work area’s plans and location of alarms, extinguishers, and exits.
1. Step 1: Rescue
Move those in immediate danger, including yourself, to safety before doing anything else.
2. Step 2: Alert
Activate the nearest fire alarm
Dial the emergency phone number for your facility
o 111 for Methodist Hospital campus and Park Nicollet Clinic (St. Louis Park campus)
o 911 for Melrose Institute, ambulatory clinics and office sites
Identify yourself and specify your department, location and type of fire. Do not hang up the phone.
Contact must be maintained with the switchboard and fire dispatcher if flames or smoke are reported.
3. Step 3: Contain the fire
Close all windows and doors
At Methodist Hospital, Melrose Institute, & 3900 Ambulatory Surgery:
i. Move visitors into rooms & instruct them to stay with patients
At Clinics and Office Sites:
i. Move visitors into the next compartment
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Clear hallways and entrances
Do not use elevators
Do not place yourself in danger.
If you are a trained emergency responder, use available equipment to extinguish the fire until help
arrives.
If you are NOT a trained emergency responder, do NOT attempt to extinguish the fire.
Attempt to extinguish the fire only if it is safe to do so.
Fire out
A “fire out” is any sign that a fire has occurred. Some examples include burned linens, scorched electrical plugs and,
everyone's favorite, burnt popcorn. Report the "fire out" to Safety and Security immediately so the appropriate
response measures can be taken.
Evacuation procedures
In the event of a fire or non-fire emergency that requires evacuation, follow evacuation procedures outlined below.
Patients should be evacuated in the following order:
1. Persons in greatest danger
Those nearest the fire or source of smoke
2. Ambulatory patients
Those who can walk out on their own and follow instructions
3. Semi-ambulatory patients
Those using walking devices, crutches, or walkers, or who need physical support and guidance
4. Bedridden hospital patients
Keep in mind the following:
Depending on the type of building and location of the fire, evacuations should first take place horizontally, or
on the same floor as the fire. If the fire continues to spread, evacuations should then take place vertically using
stairs (not elevators), or on neighboring floors.
Elevators are not to be used in the event of a fire.
Hospital team members should know their route of egress. Ambulatory clinic and office site team members
must identify an external meeting location to account for the safety of team members, patients, and visitors.
Emergency Alert: Mass Influx
Emergency Alert: Mass Influx prepares Methodist Hospital to receive a large influx of patients in from an external or
internal disaster.
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An external disaster is one that occurs in the community and may result in a sudden influx of patients to
Methodist Hospital Emergency Center.
An internal disaster, such as structural damage from severe weather, may result in an influx of patients into
other areas of the hospital.
Facility Alert: Severe Weather
Park Nicollet’s Severe Weather Plan is designed to direct team members in an established severe weather response.
How will you be notified of potential severe weather?
Methodist Hospital, Melrose Institute, and Park Nicollet
Clinic – St. Louis Park campuses
Ambulatory clinic and office locations
outside of St. Louis Park
Weather conditions are monitored by Safety and Security
Officers who will notify the site administrator of any
change.
conditions. Prepare at least three people at each
ambulatory and office site to be responsible for
monitoring weather conditions specific to that facility.
Severe weather safe area
When instructed, seek shelter in safe areas during severe weather.
Safe areas are located throughout PNHS facilities and have the
following characteristics:
Interior room: a room not located along the exterior walls
of the building.
Latching door
No windows
Small ceiling span: a smaller room is generally better than a larger room, although there are exceptions to this
rule, such as some of the meeting rooms at the Heart and Vascular Center.
Severe weather: What do you do?
When severe weather occurs, follow these directions in order to maintain the safety of our patients, visitors, and staff.
Always (all weather conditions)
Severe thunderstorm watch
Monitor weather conditions.
o Keep calm and reassure patients and visitors.
o Close all patient room and hallway doors.
o Close window blinds and curtains.
o Move visitors from waiting areas with windows.
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o Refresh your memory on where safe areas are located.
o Pay special attention to further overhead announcements.
o At offsite locations, continue to monitor your weather radio for warnings in your geographical area.
o Report any problems to your supervisor.
“Take cover” announcement
o Limit or avoid use of elevators.
o Stand by for further instructions or announcements.
o At offsite locations, continue to monitor your weather radio for warnings in your geographical area.
“All clear” announcement
o Return patients and visitors to regular locations.
o Report any damage to facilities.
Threat Assessment and Response Protocol
The PHNS Threat Assessment Response Protocol provides a standardized process for identifying, investigating and
resolving threats which have the potential for harm to persons on PNHS properties and/or disruption of business
operations or continuity of our systems and infrastructure.
What is a threat?
A threat refers to any verbal or physical behavior, communication or device that could be interpreted as
communicating or conveying any one of the following:
intent to cause emotional or physical harm or injury to persons
intent to interrupt business services or continuity
intent to cause damage to property
Examples of types of threats
Personal threat: for example, a person threatens the safety of another person on PNHS property.
Bomb threat
Weapons threat: for example, a person threatens they will use a gun on PNHS property.
Infrastructure threat: for example, threats to take down the computer network or contaminate the ventilation
system.
Who should you notify?
Depending on the threat, you may alert any of the following (an immediate response into the reported event will be
initiated):
• Human Resources
• Risk Management
Weapons policy
PNHS bans weapons on all PNHS owned or leased properties, which includes inside buildings, surrounding grounds, and
parking lots. The ban covers all individuals on PNHS property, but the ban does not apply to on-duty law enforcement.
Individuals finding themselves on PNHS properties with a weapon are expected to comply with this ban by one of the
following means:
• Leave the property
• Secure the weapon in a secure lockbox or trunk in their vehicle
• Turn it over to Safety and Security to be stored in the departmental lockbox
You encounter or become aware someone with a weapon. What do you do?
Advise your department or area leader of your observation.
IF there is no immediate threat or danger, consider approaching the individual and advising them of the
corporate ban on weapons.
IF there is an immediate threat to safety, team members are expected to move anyone in danger as is
reasonable, without risk of bodily harm and contact the appropriate response provider based on location.
Methodist Hospital, Melrose Institute and Park Nicollet Clinic–St. Louis Park campuses
Promptly provide all pertinent information.
• Call Safety and Security (3-5101) or
• Call the campus emergency number (1-1-1)
Ambulatory clinic and office locations outside of St. Louis Park
• Call local law enforcement (9-1-1)
• Call Safety and Security (3-5101) for support and response as needed.
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Security Alert: Active Security Threat
For a person actively or attempting to actively harm others. In the event of an active security threat in your area,
choose the option that will best increase your chance of survival and safety.
Safest response options
1. Run
If there is an escape path, take it, bring patients, visitors and others with you if you can, leave
belongings behind, call 9-1-1 when it’s safe to do so
2. Hide
Find a lockable room, and lock/block the door, silence your cell phone, pager, and all electronics, turn
off the lights if you can, and remain quiet, hide behind large, solid objects that could protect you
3. Fight
If you have no other options, fight back! Throw objects, yell and distract the attacker, improvise
weapons, commit to your actions.
Follow police direction at all times
Follow all instructions by law enforcement. Keep hands visible at all times. Law enforcement’s top priority is stopping
the threat; help for the injured is on the way.
Security Alert: Missing Person
Don’t wait to alert others:
Your supervisor, manager, and/or other team members in your immediate area can assist in gathering additional help
and making the necessary emergency notifications.
Make Emergency Notifications:
-Dial 111 to immediately notify a Switchboard Operator
All other PNHS locations:
-Make overhead and face-to-face notifications to alert others and get help
-Diale 9-911 to notify your local police department at your site leader’s direction.
Contact Safety & Security directly at 952-993-5101
Site leaders will evaluate the need to contact family members of missing person.
Search for the person
Watch exits and hallways to ensure that the missing person does not leave.
-Search your department and immediately adjoining areas
-if the missing person is a minor (under 18), post someone at all department exits as able and ask everyone
to remain where they are until an all clear announcement is made.
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-request assistance from Safety & Security and/or law enforcement if that person is found and unwilling to
cooperate.
Gather as much information as possible from a safe distance
-physical appearance of the suspect and victim
-what they are wearing
-vehicle description, license plate number and direction of travel
Don’t put yourself in danger by attempting to stop someone by yourself.
The Hospital Incident Command System (HICS)
In an emergency, agencies such as hospitals, law enforcement, medical transportation, local governments, and fire
departments can communicate more efficiently when all agencies follow the same command structure. This structure is
called the Incident Command System (ICS). ICS customized for hospitals is called the Hospital Incident Command
System (HICS).
In large emergency events, PNHS may activate the Hospital Command Center (HCC), using HICS to assign roles and
responsibilities. The HCC will coordinate the emergency response from a central location and will work with the
community partners such as the fire department or EMS, as well as other hospitals.
HICS model
The HICS model defines a chain of command for managing Park Nicollet's emergency response and ongoing operations.
In a disaster, the Incident Commander (IC) is the person responsible for giving overall direction for hospital or clinic
operations during the emergency situation. The person assuming the role of Incident Commander will vary depending
on who is on duty and the nature of the emergency. The IC is the only position that is always activated in HICS.
Other HICS positions will be assigned as necessary based on what is required to respond to the event. These positions
include:
• Section Chiefs for Operations, Logistics, Planning, and Finance/Administration
Each position has a job action sheet that acts as checklist of responsibilities and accountability, and to prompt specific
actions for that job duty. The most qualified person will be assigned to a position, not necessarily the most senior
person.
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Harassment, Offensive and Disruptive Behavior, and Workplace Violence This section was developed as part of Park Nicollet's commitment to providing a safe, healthy, and productive work
environment. In order to achieve such an environment, it must be free from intimidation, hostility, discrimination,
violence, retaliation, and other inappropriate behavior. All Park Nicollet tem members have the right to work in a
professional setting, free from harassment or violence, where they are treated with respect and dignity.
What is sexual harassment?
Sexual harassment includes sexual advances, requests for sexual favors, and other verbal or physical conduct of a
sexual nature.
• Creating an intimidating, hostile, or offensive environment
• Interfering with an individual's ability to perform his or her job
• Adversely affecting an individual's employment opportunities
Any type of sexual harassment is prohibited at Park Nicollet.
What about consensual relationships between coworkers at PNHS?
Park Nicollet recognizes that consensual relationships exist between team members that are, or have the potential to
become, sexual in nature. These relationships are often problematic because conduct that is consensual during the
course of the relationship can become unwelcome if the relationship ends. Although Park Nicollet doesn’t prohibit
these types of relationships at work, the issues that these relationships can create need to be considered.
Park Nicollet strongly discourages intimate relationships between leaders and their direct reports.
What is non-sexual harassment?
Non-sexual harassment is harassment that is not sexual in nature. Park Nicollet prohibits this and any type of
harassment.
Creating an intimidating, hostile, or offensive environment
Interfering with an individual's ability to perform his or her job
Adversely affecting an individual's employment opportunities
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Race
Color
Creed
Age
Gender
What is not considered harassment?
Although Park Nicollet encourages team members to report all suspected cases of harassment, reports are occasionally
made for situations that, although unpleasant or uncomfortable, don't meet the criteria for harassment.
Following are some examples of behavior that are NOT considered harassment:
Monitoring or tracking of absenteeism and performance by a leader
Administering disciplinary action either by warning or suspension for failure to meet expectations
Receiving constructive feedback on a performance appraisal from coworkers or a leader that may be negative
in nature
Denying a vacation request due to a business need
Being asked to supply a medical doctor’s note to Employee Occupational Health & Safety (EOHS) for a missed
day due to illness
performance of teams. For example, disruptive behavior can foster medical errors, contribute to poor patient
satisfaction, contribute to preventable adverse outcomes, and ultimately increase the cost of care. Safety and quality
patient care is dependent on teamwork, communication, and a collaborative work environment.
Workplace violence
Our organization-wide workplace violence prevention team is working to create a safe environment for everyone.
What is workplace violence? Violence refers to a broad range of behaviors including (but not limited to) physical violence, intimidation and/or behavior disruptive to the environment generating concern for personal safety of others (visitors, patients, individuals, clients, students and others who are present in the facility every day). High Risk Factors
Be aware of high-risk factors and signs will help you recognize the potential for incidents of workplace violence:
History of Violence
Verbal signs
Paying close attention to what people are saying can help you know if someone may become violent. People often
show their anger through words and tone of voice. In fact, this is often one of the most obvious early warning signs of
aggression.
You can see an example of each of these verbal signs of violence below.
DISRESPECTFUL BEHAVIOR: The individual starts to raise their voice, become louder and disrespectful; starts
swearing.
THREAT: “I will come down there and find that nurse and punch them!”
INTIMIDATION: “If I don’t get a meeting with that leader today, then I will have you fired.”
Non-verbal signs
In many cases, people may not tell you they are angry or frustrated. That is why non-verbal warning signs are
important.
Review below to see what these warning sign looks like.
BODY LANGUAGE: An individual’s body language can tell you a lot. Examples of body language that may be a
sign of increasing aggression include pacing, clenched fists or jaws, arms held across the chest and heavy
breathing.
THREATENING GESTURES: Threatening gestures are a more obvious warning sign. These gestures include
pointing fingers, shaking fists or moving too close to you.
HOW A PERSON LOOKS AT YOU: How a person looks at you can also be a sign. They may look away from you or
avoid you, or they may narrow their eyes and stare at you. If you perceive a threat from the person’s eye
contact or lack of eye contact, take it seriously.
BODY MOVEMENT: And finally, there may be a change in the way the person moves their body. They may look
like they are going to run away, stretch their muscles, or even come at you.
Other signs
Here are a few other warning signs of violence:
THEATS OF SELF HARM: “If you can’t make this bill go away, I will kill myself.”
THREATENS OF HARMING OTHERS: “If one more person tells me I can’t smoke here, I am going to throw
something.”
WEAPONS IN THE WORKPLACE: A person says “I’m angry” and then grabs scissors from a table and holds it in a
threatening manner.
SIGNS THE INDIVIUDAL IS UNDER THE INFLUENCE OF ALCOHOL OR DRUGS: The person is calm one moment and
all the sudden becomes loud and threatening.
How to respond: Know the stages of aggression
Knowing the stages of aggression can help you determine how to respond. Remember, the goal is to recognize signs as
early as possible and respond before a situation gets worse (escalates).
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ANXIETY: Anxiety may look like irritability, inability to sit or stand still, discourteous or disrespectful
communication.
AGITATION: Agitation may appear as extreme nervousness, pacing, hostility, harassment or bullying.
ACTING OUT: Acting out is when the person verbally threatening, calling names, throwing items or striking out.
How do you respond?
Next we will look at different ways you can encourage someone’s behavior to de-escalate (to reduce the intensity of a
conflict or potentially violent situation), when it is safe to do so – and when you should call for help.
Communication
How you interact with someone can make a big impact on their mood and how they respond to you.
BODY LANGUAGE: Adjust your body language. Just as someone else's body language can trigger a warning sign
for you, how you present yourself can do the same for them. Stand with your arms at your side, hands hanging
downward and use appropriate eye contact; do not stand with your hands on hips.
TONE OF VOICE: Maintain the appropriate tone of voice. A caring tone can help calm the environment and the
person. The tone of your voice can either calm the incident or cause the incident to escalate.
SIMPLE LANGUAGE: Speak in an even rhythm and use simple language as much as possible. Using “big” or
uncommon words can increase frustration. When giving instructions, try doing it in three words, such as
“Please follow me” or “Please sit down.”
VOLUME: Adjust the volume of your voice. Speaking in a soft volume that can still be heard easily can help
someone relax. Do not match the volume of the person.
Active Listening
Many of our patients and members just want to be heard – they want us to really listen to them. Active listening can
help de-escalate behavior.
• JUST LISTEN: Listen. Silence is a powerful tool.
• ASKE QUESTIONS: Ask simple questions. Take some time to allow the patient to express their concerns, or tell
you what they need. Use simple, open-ended questions such as, “How can I help?”
• VALIDATE CONCERNS: Validate the concerns of the person you are talking with. This shows them that you are
listening, that you understand – and that you care.
• USE “I” STATEMENTS: Try using “I” statements. Without turning the focus on yourself, respond to the person
with how you would like to help. Focus on the problem – not the person. An example of this is, “When you talk
so quickly, I can’t hear you.” Or, “I’m sorry that experience happened to you. I want to help. What can I do
now?”
• GIVE TIME: Give people time to think. If you find that an individual is not responding to your questions, try
“Taking 5” with them and ask questions about their personal life. Or, take a break and let them know that you
will come back later. Giving them time to process information can help future conversations.
Call for help if you feel uncomfortable or unsafe
If you feel uncomfortable or unsafe in a situation, leave and call for help – before a situation gets worse (escalates).
Immediate on-site resources are available if you are experiencing an unsafe or threatening situation.
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Call for assistance: when additional resources are needed
Call for help: when concerned about active security threats or bodily harm
Call for assistance: Contact your department or site leader
Call PNHS Emergency Number (111)
Call for help: Methodist and St. Louis Park Clinic Campuses call PNHS Emergency Number (111)
All other sites call 911
What to report
Reporting violence is important in helping create a safer workplace. Your role in reporting events is critical.
Please report:
VERBAL OR WRITTEN THREATS: One example - Your patient begins calling you names, yelling and/or
threatening you for any reason.
VERBAL ABUSE: One example -The caller on the phone swears at you and threatens you.
PHYSICAL ASSAULTS: One example - Your patient with dementia or brain injury starts hitting, spitting, kicking
and biting you during care or interventions.
ANY PERCEIVED ACTS THAT CAUSE FEAR OR HARM: One example - Frustrated visitor in the waiting room
throws magazines at the front desk attendant.
Where to document events
Best Care Reporting System
What is an Active Security Threat?
An active security threat describes a situation when a person or persons are being harmed, or are at immediate risk for
harm.
Responding to an Active Security Threat
Events involving weapons are rare and unlikely, but it’s important to plan to protect ourselves, our patients, and others.
“Run, Hide, Fight” is short and simple plan that offers the best chance of survival.
Run -Try to escape, with our patients & visitors as able
Hide - Seek cover if escape is not possible
Fight - Only as a last resort
RUN: Escape if possible
When another person is harming or attempting to harm others in the area, and a safe escape path is available, RUN.
• We should help our patients and visitors as much as possible; however, don’t delay your escape for someone
refusing to leave.
• Have a basic plan in mind, along with a plan for what to do when leaving the area or building.
• When you run, leave your belongings behind. Stuff can always be replaced; you can’t be. Remember to keep
your hands visible at all times when running, and do not return until you receive an “All Clear” announcement.
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HIDE: Stay hidden until “All Clear”
When the exact location of the threat or suspect is unknown, or escape isn’t possible, hiding may be your safest option.
When you hide:
• Make sure your hiding spot is out of view.
• Encourage patients and others to hide with you. Assist them if possible
• Block entry to your hiding spot, and lock doors if you can.
• Hide behind large, solid objects that will help protect you.
• Silence all electronics such as cell phones and pagers.
• Remain completely quiet and as calm as possible. If others are with you, tell them to do the same.
• Remain hidden until the announcement of “All Clear” has been made.
FIGHT: Use objects in your area
• Fight back when you have no other options or when you are faced with a life-threatening event.
• You must fight as though your life depended on it, because it does.
• You cannot hesitate or delay your actions.
• Throw items at the suspect, hit them with solid objects, or punch and kick them if you are close enough.
Calling for help
Report only what you know
If an Active Security Threat happens, call for help as soon as it is safe to do so. A work phone may help identify where
you are. When you call for help, there is important information you can provide, if you can. This includes:
• The location of the threat
• The number of suspects
• Physical descriptions of the suspect(s): clothing type, skin color, hair color, visible scars or tattoos, or anything
else that makes them stand out.
• The type of weapon used or held by the suspect, such as “handgun,” “long gun,” “knife,” “baseball bat,” etc.
• The number of victims in your area.
Panic or duress buttons
If panic or duress buttons are available at your location, press them if it’s safe to do so. When able, provide responders
with information about the situation.
If safe to do so, provide responders with additional information
Call your site support response team
Know the policies and procedures for your location
Responders to an alarm may take several minutes to arrive, take action as needed while waiting
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Announcements
If you hear an announcement similar to “May I have your attention please: Active Security Threat. Methodist Hospital,
second floor lab,” figure out what you will do with that information.
• Act immediately -- Do not delay your actions.
• Do not call for additional information.
• Call only if there is an emergency in your area (and it is safe to do so) or if you have information that can help
responders.
What is the Epic Aggression Flag?
The Epic Aggression Flag is a next step in providing a safe and healing environment for everyone.
The Aggression Flag is like other patient chart advisories found in Epic.
Its purpose is to alert us to a situation we should be aware of regarding a patient in our care.
When is an Epic Aggression flag placed?
A patient’s behavior determines the use of the Aggression Flag. The flag indicates a patient has demonstrated one or
more of the following:
• Physical assault
• Physical actions with the intent to intimidate or cause physical harm
• Verbal or written threats with the intent to cause physical harm
Once the flag is placed, its purpose is to raise awareness about a patient who may have the potential to harm others
and to remind us to implement safety measures as necessary.
Discuss with your leader the process and who is responsible for placing an aggression flag on a patient chart.
Want a more in-depth refresher course?
Talk to your leader about additional courses that may be available in your area including:
• Workplace Violence Prevention Level 1
• Activity Security Threat
• Epic Aggression Flag
Harmful intent versus harmful impact
Individuals accused of harassment or violent conduct may argue that their behavior was not intended to be offensive or
threatening. However, lack of intent is NOT a defense against these acts. The offense does not need to be intentional in
order to be considered harassment or violent conduct.
Who is covered by these policies?
All PNHS team members, patients, visitors, independent contractors, volunteers, students, vendors, and employment
applicants.
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These policies extend beyond the immediate workplace. Conduct prohibited by these policies is also unacceptable in
any work-related setting outside of the workplace, including but not limited to business trips, business meetings, and
work-related social events.
Addressing the offender
Park Nicollet encourages team members that feel they are being subjected to harassment or violent behavior to first
advise their offender that the behavior is unwelcome and to make a demand for it to stop.
If for any reason the individual does not feel comfortable addressing the offender or if such action does not cause the
offensive behavior to stop immediately, report the incident using the resources described in this section.
Reporting an incident Park Nicollet encourages the reporting of all perceived incidents of discrimination, harassment, violence, or retaliation.
This applies regardless of the offender’s identity or position within the organization.
Individuals who believe that they are the victim or witness of such conduct should immediately discuss their concerns
with their leader. In the event that your leader is the offender, notify the next level leader within your department.
Ways to report a violation
Contact your leader
Call Employee Relations at 952-993-1699
Call the Compliance Hotline at 952-993-2320
Call Safety and Security at 952-993-5101
Call the Employee Assistance Program at 800-383-1908
Anti-retaliation statement
As part of Park Nicollet’s commitment to a healthy, harassment free environment, team members can be assured that they can bring complaints forward in good faith without risk of negative consequences. Retaliation against an individual for bringing forward an allegation or for participating in an investigation of harassment or violence is a violation of Park Nicollet’s policy. Such conduct will result in corrective action up to and or including termination of employment.
If your role at Park Nicollet Health Services does not involve patient care,
STOP here and proceed to:
Page 60: Sign Acknowledgement Forms and return to leader
Complete Additional Integrity & Compliance Courses
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Additional Required Education for Patient Care Roles If you are in a patient care role, please complete the tasks listed in the table below. Please note that patient care roles
require additional education which will begin on the next page (38).
If your role is…. Task Page
Patient care or
Read required education:
Orientation to our Code of Conduct, Privacy, Security and Compliance program
Emergency Management
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Advanced Corporate Compliance for the Patient Revenue Cycle
Hazardous Waste for Healthcare Workers
Patient Safety
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Patient care or
Advanced Corporate Compliance for the Patient Revenue Cycle This section is designed to provide you with a review of basic Corporate Compliance requirements, concepts and
policies, and to describe how they apply to Park Nicollet team members who are involved in the Revenue Cycle.
Following guidelines to produce timely and accurate claims and patient bills helps us achieve our mission and ensures
that we are in compliance with the laws and regulations that govern our business.
The Revenue Cycle Process
A great number of team members at PNHS are involved in the revenue cycle process. Due to the number of
departments involved in the revenue cycle, teamwork is essential.
Understanding the work of the departments and how patient data flows in the revenue cycle is the key to compliance.
The revenue cycle is one integrated process in which all players must understand their role and how they influence the
whole.
The pieces of the revenue cycle are Registration, scheduling, and check in; Clinicians and coding; and Billing and
payment.
Registration, scheduling and check in
Team members in registration, scheduling, and check in roles perform several major tasks that are vital to the efficiency
and financial welfare of our organization.
These key tasks include:
• registering and scheduling patients
• obtaining completion of the patient consent form
• obtaining the Medicare Secondary Payer Questionnaire
These major tasks help our patients get their claims paid correctly by their insurance coverage the first time.
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Task 1: Register and schedule patients
Registering patients is an important part of the patient revenue cycle. If patients are not registered correctly, there are
implications throughout the cycle, including wrong address, wrong age, wrong social security number, etc.
Information must be gathered from the patient during the registration process such as the patient's address, telephone
number, next of kin, and date of birth.
After registration is scheduling. Scheduling also has implications for the patient revenue cycle, including the potential
for coding to be incorrect by the clinician. Scheduling too soon may mean a visit may not be covered by insurance.
Scheduling the wrong type of appointment may cause patients to be upset when clinicians do not have enough time to
spend with them for multiple issues.
Task 2: Confirm patient identity
The check-in process can set the tone for the rest of the patient’s visit. When our patients are welcomed, put at ease,
and have a timely check in, they can be roomed more quickly, which can enhance their overall experience.
One of the first elements of check in is to confirm patient identity by checking the photo ID in accordance with the
Identity Theft Prevention, Detection and Mitigation (ID Theft) policy.
Mistakes in patient information can carry over to the claim form causing claim rejects, delays in processing, and even
denials. These mistakes cause more work and can be quite costly for our organization.
Report any discrepancies and potential cases of ID theft using the process and form included in the policy.
Task 3: Verify insurance information
Patient's insurance information should be scanned at the patient's visit and verified at each patient visit to ensure
accuracy and to make any necessary changes.
The pieces of information that we need to pay close attention to and collect from the patient are:
• exact legal name of patient
• relationship to subscriber (name/date of birth)
• name and address of insurance company
• type of coverage
The accuracy and verification of insurance information is extremely important because that information will be used on
many claim forms and medical documentation materials throughout the patient's history.
Task 4: Obtain copayment and deductibles
Team members in frontline and registration roles are responsible for collecting patient copayments. Park Nicollet
Health Services collects copayments, prepayments, or other amounts owed by a patient (or his/her legal
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representative).
PNHS team members shall not routinely waive copayments or deductibles. Waivers of copayments in cases of indigency
shall be made only in accordance with applicable law, payer contracts, and the PNHS Collection and Charity Care
policies.
Task 5: Obtain the Patient Consent form
Another crucial compliance task that takes place in this phase of the patient revenue cycle is obtaining the Patient
Consent form.
Park Nicollet designed Patient Consent forms for Methodist Hospital and Park Nicollet Clinics, including TRIA, to meet
Minnesota state requirements, assignment of benefits requirements, and HIPAA requirements.
It is important to make sure the patient understands the information on the form.
Once the consent form is completed, dated, and signed, it should be sent to Health Information Management
(HIM) to be scanned into the consent section of the patient's chart.
Task 6: Obtain MSPQ
Front Line and Registration team members are responsible for obtaining the Medicare Secondary Payer Questionnaire
(MSPQ or Medicare Questionnaire). Medicare uses the term Medicare Secondary Payer when Medicare is not
responsible for paying the claim first. Registration is responsible for determining if a patient's Medicare coverage is
primary or secondary to any other insurance coverage. Team members are required to conduct admission interviews
using a questionnaire to determine if Medicare is primary or secondary.
The Medicare Secondary Payer questions will help you determine if the beneficiary is:
• covered by another policy or government program.
• potentially eligible for coverage by a different insurer due to an accident or injury that makes a third party
liable for medical expense.
• eligible for coverage of all expenses over the amount Medicare covers.
Medicare Secondary Payer questions must be asked of every Medicare hospital patient and recorded in the electronic
medical record. The Medicare Secondary Payer Questionnaire is located in the electronic medical record. Performing
these steps correctly protects Medicare funds and ensures that Medicare does not pay for services that are the
responsibility of private insurance plans or other programs.
Clinicians and coding
In this phase of the Patient Revenue Cycle, clinicians and coders ensure that documentation and codes are accurate.
Medical documentation must be maintained to support the diagnosis codes and services reported.
A responsibility of clinicians that greatly affects the patient revenue cycle is documentation and coding. Proper
diagnosis coding involves identifying the appropriate codes for the patient's conditions or symptoms. Clinicians are also
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responsible for coding correctly for items and services provided. The patient records are then used as the basis for
reimbursement on claims.
One important consideration for compliance with documentation guidelines at PNHS is to be timely in the dictation and
signing of medical charts. As so many parties are involved in and affected by documentation, delays can occur many
places in the patient revenue cycle, leading to claim denials and inaccurate patient bills.
To support our commitment to timely and accurate documentation, PNHS has policies regarding timely completion and
authentication of records.
Diagnostic tests, such as X-rays, lab or other diagnostic tests, must be ordered by a physician or appropriate
practitioner. Errors may occur in billing if the clinic or hospital documentation does not clearly indicate the physician
who ordered the diagnostic tests. It is wrong to list one person as ordering a test when, in fact, another person ordered
the test.
Some common errors that occur, causing unnecessary delays in the overall Patient Revenue Cycle, are insufficient
documentation, missing or no documentation, unsigned documentation, insufficient accident information, and/or
undated or incorrectly dated documentation.
Timely dictation and signing of charts
Every healthcare provider is required to document the clinical services performed on behalf of individual patients. This
includes services at hospitals, physician offices, clinics, home care, hospice, and ambulatory settings. Healthcare
providers include licensed practitioners such as physicians, nurses, psychologists, allied health professionals, clinical
social workers, case managers, and licensed independent practitioners (for example, physician's assistants).
Accreditation and regulatory standards require healthcare providers to create and maintain a separate record for each
individual patient that is treated. Specific data elements are required.
Health Information Management's (HIM) purpose at Park Nicollet Health Services is to manage paper and online clinical
documentation that is generated and used for patient care.
HIM is responsible for the following processes: managing clinical documentation for patient care, release of
information, transcription, document imaging, and chart completion.
Documentation: Patient care
A major responsibility of clinicians is documentation of the services that they provide. Although providers are
responsible for the bulk of documentation in medical records, it is the responsibility of every authorized PNHS team
member providing patient care to include any necessary documentation to a patient chart.
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A medical record is only accurate if all services provided and items used or ordered are documented. Correct and timely
documentation must take place in order to comply with Corporate Compliance policies, but documentation is
important for many other reasons as well, including:
• Charges submitted to payers are based on documentation.
• Documentation is the legal record for malpractice claims and payer audits.
• Management decision making uses documentation to determine the type and level of care.
• Communication and continuity of care among physicians and other healthcare professionals is essential.
• Providers must sign their dictations. This is a requirement.
Physician order for diagnostic tests
An order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed
for a beneficiary. The medical record and/or the request itself must clearly document the physician's intent for the
diagnostic test to be performed.
The following are examples of acceptable documentation:
• An order, signed by the physician
• A signed requisition/Medical Service Record (MSR)
Note: A requisition/MSR, or order, not signed by the physician does not support physician's intent for the
test to be performed
• A notation in the patient's medical record documenting the need for or the intent to obtain a specific test,
signed by the physician
• A verbal or telephone order - documented at both the treating physician's office and the testing facility - and
placed in the beneficiary's medical record
Note: Must be signed within the time frame specified by the state
• An email from the physician that may be verified
• Another type of electronic requisition transmitted from the treating physician to the testing facility that
requires a password, with proof of the process in writing (e.g., attestation)
Charge entry
At Park Nicollet Clinics, the providers initiate charges by entering Current Procedural Terminology (CPT) and diagnosis
codes out of Computerized Provider Order Entry (CPOE).
At Methodist Hospital, the task of charge entry can take place across a number of different departments.
Regardless of the setting, we are able to promote accurate charges being entered by keeping correct and complete
documentation.
A critical aspect of this task is that the charge is entered for the correct patient, with the correct date of service, and the
correct provider identification number/billing number.
Coding: Introduction
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Professional clinic coding: For Park Nicollet Clinicians providing services at a clinic, clinicians are expected to
select appropriate ICD-9 diagnosis and CPT procedure codes for all services performed during that visit. The
documentation must reflect these services.
Professional coding in the hospital: Park Nicollet clinicians are also expected to assign CPT and diagnostic codes
for their hospital evaluation and management visits and some procedures using the Navigator. Charges are sent
to professional coders via the Charge Router and checked for accuracy.
Hospital facility coding
with nationally recognized ICD-9-CM and CPT-4 guidelines.
After patient records are coded and entered, the Coding Department extracts information from the medical record to
meet Uniform Discharge Data Set guidelines. This data is then used for compiling, running and analyzing research study
requests.
Coding as part of the patient revenue cycle
Just as documentation serves as the primary communication engine between all of the PNHS parties that are involved
in patient care, coding serves as the means for PNHS to communicate with our third party payers.
The process is Patient Care > Coding > Billing.
ICD-9-CM and CPT-4 codes ensure that we are speaking the same "language,” whereas non-standardized, narrative
explanations leave room for interpretation. Precise coding is essential to submitting compliant claims and thus being
correctly compensated for the services we provide. Coders must follow nationally recognized coding guidelines.
The Coding Department can only code what is documented in the chart. If a charge is present, but no documentation
exists, the Coding Department cannot code the charge. Therefore, it is extremely important that clinicians document
with sufficient detail for the coders. The Coding Department must have access to the necessary documentation to code
from before the claim can be released for billing.
If documentation is in question, you may need to query the clinician. If there is no documentation to substantiate the
charge, the charge should be removed after discussing with your leader.
Coding: Special considerations
Coding practice is the transformation of descriptions of diseases, injuries, conditions, and procedures from words in the
medical record to alphanumerical designations for billing purposes.
Coders must be able to assign codes to all codable information. Information used to assign codes must be part of the
official health record, not part of an unofficial document such as a surgery log or registration list.
Coding responsibilities
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All PNHS professionals and others involved in the revenue cycle shall:
• Adhere to the ICD-9-CM, ICD-9-CM Official Guidelines for Coding and Reporting, coding conventions, official
coding guidelines, the CPT rules, established by the AMA, and any other official coding rules and guidelines
established for use with mandated standard code sets.
• Only assign and report codes that are clearly and consistently supported by physician documentation in the
health record.
• Not change codes or the narratives of codes so that the meanings are misrepresented. Diagnoses or procedures
should not be inappropriately included or excluded because the payment or insurance policy coverage
requirements will be affected.
• Assist and educate physicians and other clinicians by advocating proper documentation practices, further
specificity, re-sequencing, or inclusion of diagnoses or procedures when needed to more accurately reflect the
acuity, severity, and the occurrence of events.
• Strive for the optimal payment to which the facility is legally entitled, remembering that it is unethical and
illegal to maximize payment by means that contradict regulatory guidelines.
• Code all documented conditions that coexist at the time of the encounter and require or affect the patient’s
treatment or care management. Do not code conditions that have been treated in the past but no longer exist.
Pre- and post-adjudication (e.g., Claims/Billing)
The Pre- and Post- Adjudication Departments (e.g., Claims/Billing) submit PNHS‘ charges to primary and secondary
payers. They ensure that claims are created and submitted in compliance with government regulations and third-party
contracts. They correct errors found prior to claim submission through system edits and manual review and also correct
errors after denial by the payer.
Not only is Pre- and Post-Adjudication responsible for correcting errors found prior to claim submission, but they must
also perform this task to get the claim submitted within timely filing limits. As you may imagine, many of the errors that
have taken place in other places in the patient revenue cycle become visible in this process.
Some of the challenges for team members involved in billing are using correct provider billing numbers, correct place of
service codes, and recognizing and adhering to the different Medicare and Medicaid billing rules.
Claim submission standards of conduct
• Claim documentation: Claims should be submitted only when appropriate documentation supports the claims
and when such documentation is maintained and available for audit and review.
• Un-bundled charges: It is not appropriate to un-bundle charges to inappropriately enhance payment. Use of separate billing codes for services that have an aggregate billing code is abusive. It is not acceptable as it may violate anti-kickback statutes.
• Billing discrepancies: In the event a discrepancy is discovered subsequent to the submission of the claim, all attempts to rescind the original claim submitted must be made in order to submit the correct claim for the services. If we have already received reimbursement, an adjusted claim will be submitted to the payer. Any member of the billing staff who identifies potential billing or reimbursement discrepancies with respect to claims already submitted to government or private payers is required to report immediately those discrepancies either to their leaders or to the Compliance Officer.
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• Records: Billing staff will not falsify, destroy or withhold records relating to any portion of the billing and claims submission function.
• Billing inconsistencies: Billing staff should immediately report to their leaders, or compliance, any billing instruction received from Payers which is inconsistent with current billing policies and procedures.
• Provider numbers: All billable providers' entered into the Billing System must have their own provider numbers (National Provider Identifiers). The billable provider who rendered the services and his/her provider number must be reported in the claim. No other provider number in the system will be used for another provider. It is fraudulent to misrepresent the provider. Any questions regarding who provided the service should be forwarded to Coding and/or the Compliance Department.
• 3-day window policy: Per the patient accounting 3-day window policy, all outpatient services connected with an inpatient stay will be bundled.
• Duplicate billing: Submitting more than one claim for the same services or submitting the same claim to more than one primary payer is prohibited. Duplicate billing can occur due to simple error. Knowing about duplicate billing, which is sometimes evidenced by systematic or repeated double billing, can create liability under criminal, civil or administrative law, particularly if any overpayment is not promptly refunded. When a claim needs to be resubmitted, Billing staff will submit an adjusted/replacement claim to avoid duplicate claims.
• Orders/medical necessity: Claims should only be submitted for services that the hospital has reason to believe are medically necessary and that were ordered by a physician or other appropriately licensed individual.
Payment: Two potential outcomes
The desired outcome of the patient revenue cycle is that we are appropriately reimbursed for the services we have
provided. The other possible outcome of claim submission, however, is that the claim is denied for any number of
possible reasons, returned to PNHS, and routed to the appropriate party before resubmitting the claim. In some cases,
denials are not payable and Park Nicollet loses the reimbursement.
Common reasons for denials include:
• incorrect insurance was billed
• Medicare Secondary Payer denials
• lack of medical necessity
Payment and reimbursement
It is unethical and fraudulent to make changes to a returned claim that is not supported in the documentation for the
sole purpose of reimbursement. We can only claim what is accurately documented in the patient record.
For example, if a patient calls to complain that their insurance denied a claim for a preventive visit, you can't change
the visit coding to that of a problem visit if that isn't the documented reason the patient was seen.
You can't charge for anything that isn't documented (e.g., drugs, durable medical equipment, and therapy sessions).
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Credit balances and bad debt
PNHS treats credit balances and bad debt in compliance with applicable law and regulations. PNHS endeavors to
accurately track, report, and refund credit balances.
Patient Financial Services team members shall monitor credit balances and refund them in a timely and appropriate
manner. If a payment results in a credit balance (overpayment) and is an improper or excessive payment made, the
credit balance will be researched and if appropriate, expeditiously returned to the source.
Abuse, fraud, and auditing
Given the complexity and interdependent relationships of the departments in the revenue cycle, proper coordination
and supervision of the revenue cycle process is important. Those involved in the revenue cycle must also protect the
organization against Medicare fraud and abuse.
Medicare abuse
The legal definition of abuse is abuse may result, directly or indirectly, in unnecessary costs to the Medicare or
Medicaid program, or improper payment for services that fail to meet professionally recognized standards of care or
are medically unnecessary.
Individuals who are guilty of Medicare abuse unintentionally follow practices that violate the guidelines of the
Medicare program and may result in unnecessary costs to Medicare.
Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has
not knowingly or intentionally misrepresented facts to obtain payment.
Medicare fraud
The legal definition of fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to
defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representation, or
promises, any of the money or property owned by or under the custody of any healthcare benefit program.
Individuals who commit Medicare fraud intentionally obtain, or attempt to obtain, money or property owned by
Medicare through false or fraudulent pretenses.
Medicare may consider a healthcare provider fraudulent if the provider identifies inappropriate actions or behaviors
against the Medicare program but fails to remedy them. Medicare expects all healthcare providers who participate in
the program to furnish and report services in accordance with the established regulations and policies.
Healthcare providers should correct any billing or reporting errors that they identify. If the errors result in
overpayments, the healthcare provider is required to return the overpaid amounts to Medicare.
The most common types of Medicare fraud are:
• billing for services that were not rendered
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procedure/revenue codes
• signing blank records or certification forms, or falsifying information on records or certification forms for the
sole purpose of obtaining payment
• consistently using procedure/revenue codes that describe more extensive services than those actually
performed
Law enforcement agencies investigating and prosecuting for fraud can choose between criminal or civil prosecution.
Criminal prosecution: The U.S. Attorney's Office may use a series of federal statutes to indict and prosecute
individuals or entities involved in fraud. Those found guilty may be subject to:
substantial penalties
fines
restitution
imprisonment
Civil prosecution: In lieu of criminal prosecution, the U.S. Attorney's Office may decide that the interests of the
Medicare program are best served through the civil courts. In these cases, individuals or entities face substantial
penalties for each violation of program rules, including repayment of up to three times the amount of damages to
the Medicare program and large fines.
Recovery Audit Contractors
Recovery Audit Contractors (RACs) are private companies contracted by the Centers for Medicare and Medicaid
Services, tasked to identify Medicare overpayments and underpayments and return Medicare overpayments to the
Medicare Trust Funds.
RACs review claims submitted by hospitals and health systems, physicians/clinicians, and other healthcare providers
and suppliers in an attempt to identify improper payments. They are highly motivated to identify overpayments and
other improper payments, as they are compensated on a contingency-fee basis, based upon the principal amount
collected from and/or returned to Medicare providers or suppliers resulting from improper payments.
Type of
service, renal dialysis, etc.
discharge disposition codes.
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PNHS has created a multidisciplinary group to work on RAC related items - Park Nicollet Health Services RAC Committee
and RAC Response Team.
The Compliance and Contracting website has information dedicated to RAC activities, called the Recovery Audit
Contractors (RAC) Program. This page provides the latest information on the RAC program expansion and Park
Nicollet's efforts and educational activities.
Many people play key roles in the RAC process at PNHS. In general, the following departments and individuals play
major roles in the RAC process:
• Ordering/treating physician
• Patient Admitting/Registration
• Charge master/Finance
Complete, accurate, and timely documentation of the patient's clinical condition is critical in order to ensure that
patients receive the appropriate level of care in the setting that the clinical condition requires, and that the hospital
receives the appropriate Medicare reimbursement for the level of care provided.
If you or your department is contacted regarding a RAC request, please know that these requests should receive
priority attention. It is essential that all our responses to the RAC inquiries be timely and complete, and there is a
complete record of documentation to support the services charged.
CMS has identified the following areas for targeted review, among others:
• Place of service errors
• Medical Necessity
• Medically unnecessary setting (billed as inpatient and should have been outpatient or observation) for some of
the following admissions (not an all inclusive list):
• medical back problems
• renal failure
Government inspections and investigations
Park Nicollet may be audited by an external source, such as Medicare/Medicaid, Recovery Audit Contractors (RACs) or
the Office of Inspector General (OIG). These reviews test the effectiveness of our Compliance Program and our
compliance with government and provider regulations.
Regarding Government Inspections, it is Park Nicollet policy that:
• All government inspections or requests for interviews or documents be referred to the Chief Compliance
Officer or legal counsel for review.
• Park Nicollet team members cooperate promptly and fully regarding possible civil or criminal violations of the
law.
You can make a difference
To ensure the financial health of PNHS, it is critical that compliance is practiced, by all team members, throughout the
patient revenue cycle. From the beginning of the revenue cycle to the completion, each successful step in the process
minimizes the hospital's Accounts Receivable days and improves cash flow.
All of the following requirements can create an overwhelming amount of overhead and responsibility:
• compliance with laws and regulations
• providing necessary care
• generating clean claims for payment
These measures are necessary to maximize the efficiency of our revenue cycle process, protect our financial welfare
and reputation, and maintain compliance with the law.
Everyone has a role to play. All of us benefit by working together.
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Hazardous Waste for Healthcare Workers This section presents hazardous waste management training required by U.S. regulatory agencies for those involved
with hazardous waste at Park Nicollet Health Services.
Hazardous waste is waste that is dangerous or potentially harmful to our health or the environment. Park Nicollet
generates hazardous waste that must be controlled in several areas. This section covers the basic hazardous waste
management requirements for medical and general waste.
Managing hazardous waste requirements
The Federal Government's Resource Conservation and Recovery Act (RCRA) gave the Environmental Protection Agency
(EPA) the authority to control hazardous waste from "cradle-to-grave." This includes the generation, transportation,
treatment, storage, and disposal of hazardous waste. RCRA also defines a framework for the management of non-
hazardous wastes.
The law was enacted in 1976 to protect our environment. It applies to businesses, schools and hospitals,
including Park Nicollet.
The RCRA requires that Park Nicollet facilities (including Methodist Hospital and Park Nicollet Clinics) follow
specific rules and procedures for disposal of hazardous waste. It also requires mandatory and documented
training for those who come in contact with hazardous waste.
In addition to the EPA, other regulatory bodies that monitor Park Nicollet’s hazardous waste management include the
Minnesota Pollution Control Agency as well as the metropolitan counties of Hennepin, Carver, Dakota, and