scope:

It is expected that each MTF will design processes that meet local needs and comply with the minimum standard business practices, processes, and reporting requirements included in this instruction. These processes include the oversight and audit of outpatient coding with specific attention to OHI for TPOCS/MSA and MACP claims, a closed medical record system, staff training to ensure that all the clinical and administrative requirements associated with an outpatient encounter are performed, and oversight of dollars, labor hours, and full-time equivalent (FTE) utilization in support of this policy.

Purpose. To designate roles and responsibilities in outpatient coding and standardize coding practices, processes and reporting requirements, to include associated financial reporting requirements. This instruction requires a mandatory audit process, a closed medical record system and the separation of functions associated with billing and coding. References (a) through (i) and enclosures (1) through (5) will be used by military treatment facilities (MTFs) to establish management controls that support patient care, management of medical records, reporting responsibilities, sustaining accurate health information data and financial reporting.