Healthcare Coding and Compliance

A. Outline a HIM compliance plan that emphasizes the coding function by doing the

  1. Describe the necessary components of the plan.
  2. Explain the responsibilities of the staff who implement each component of the plan.
  3. Explain the link between HIM and three external agencies that monitor compliance.
    a. Explain how these agencies disseminate information.
    B. Outline guidelines for implementing this plan by doing the following:
  4. Describe elements to be included in the policies within the plan.
  5. Explain how coding accuracy will be monitored.
  6. Discuss processes for reporting noncompliance internally.
  7. Explain a corrective action plan in circumstances of noncompliance.
  8. Describe the course of action if external audit identifies coding noncompliance.
  9. Discuss how the plan should be evaluated.
    Note: In your discussion, identify who evaluates the plan.
    C. Outline the elements of a coding compliance training program by doing the following:
  10. Explain how needs would be identified.
  11. Describe the who/what/when/where of the training program on a brief sample agenda for
  12. Explain how the training program should be evaluated.
    D. If you use sources, include all in-text citations and references in APA format.STOP


Healthcare Coding and Compliance

In a healthcare organization, it is important that coding and compliance programs are put
in place to ensure that the records pertaining to the billing of patients are well kept. Health
information management (HIM) compliance programs including coding function are critical in
effective functioning of the healthcare organization. For instance, third-party-payers are
reimbursed upon accurate coding system. Therefore, laughing HIM compliance programs with
the organizational compliance standards and principles as required by the regulatory agencies is
required. The paper delineates on various concerns about coding and compliance programs in a
healthcare organization.
HIM compliance plan
Currently, many healthcare providers are developing and implementing compliance
programs in an effort to ensure that they adhere to ethical business practices in accordance with
the compliance program guidance from the department of health and humanities services office
of the inspector general (OIG) (Department of Health and Human Services 2006). The shift of
effects has been promoted by the increase in severity of penalty provided by the health insurance
portability and accountability act HIPAA passed in 1966 under the public law 104- 191 and the
balanced act of 1997 under the public law 105- 33. Therefore, risks of civil and criminal
litigation have been reduced by adhering to these stipulated laws and compliance programs.
In the case of Juliette as the new health information management (HIM), she is required
to develop compliance plans that are in line with the hospitals compliance plans. The
compliance program needs to focus on the coding compliance and standards that meet the
threshold of the external agencies.

Components of the plan
The compliance plan needs to have these components; oversight, policies and procedure,
communication, education, auditing, monitoring, and disciplinary policy and action. The plan
should have oversight components, which will ensure that all the programs are working as
anticipated. The oversight component is responsible for the overall operation of the organization
as it ensures that the coding is done appropriately and that all the systems in the organization
flow well (Bryant, 2007, p. 21). The OIG requires that policies and procedures in an organization
address areas of special concerns in accordance to the OIG compliance and guidance for the
hospitals. Some of the risks addressed in the policies pertains to billing of items that are not
rendered, up coding, rendering outpatient services in conception with the inpatient systems,
documentation issues among others. Therefore the policies and procedures should ensure that
coding and billing in the organization, are based on accurate and timely medical recorded
documentation, continued review of procedures and rejected claims among other issues.
Another important component is audit and monitoring. The plan should have adequate
monitoring and auditing program to ensure compliance and adherence to the right policies and
procedures set. It is important in helping in identification of potential risks and areas that
required additional education. Auditing helps in ensuring that problems with duplicate outpatient
billings and cases where bills are transferred as discharges are identified and sealed.
Roles and responsibilities of the plan
For effective implementation of the compliance plan, it requires the support of various
people in an organization. These personnel work under the HIM but must ensure that they uphold
to their responsibilities in implementing the various components. An oversight officer also, the

corporate compliance officer requires a HIM professional that is qualified to provide proper
leadership and management function. The officer is required to ensure that the organization is
adhering to the ethical practices in coding and in executing its tasks (AHIMA 2013). The HIM
professional responsibility is to ensure that there is accurate documentation, billing and ensure
that coding comply with the healthcare compliance. Therefore, this officer plays a fundamental
role in ensuring that the healthcare organization runs smoothly at the same time complaining
with the set standards and policies.
HIM professionals with the responsibilities of ensuring that policies and procedures are
adhered perform various duties. They actively participate in the development of organizational
policies and procedures that are complete, accurate, and ensure that the documents are recorded
on timely basis. They also ensure that coding is carried out at the right time. They also ensure
that the organization retained health records and maintains patient’s confidentiality as required
by the federal and the state laws. They also ensure that there is proper identification of any
coding errors in the organization.
Auditors in charge of carrying out auditing and monitoring are also important in ensuring
that the organization performs its duties well and adhered to ethical standards set. These
professionals are charged with the responsibility of ensuring that compliance and policies and
procedures are adhered to. They also design audit protocols and are involved in analyzing of
data, which helps in developing of audit and monitoring processes. They also evaluate results of
their audits and provide recommendations. They also assist in carrying out audits in other
departments in the organization. They may also use their data analysis skills in helping
administration and the corporate compliance officers to analyze the findings of their audit

The link between HIM and three external agencies that monitor compliance
HIM responsibility is to ensure that the organization complies with the set policies and
practices. The relationship between the HIM and external agencies is therefore essential to
ensuring that they work well as per the set standards and regulations. This is only achieved
through effective communication. The three major external agencies that the HIM needs to be in
touch with include; the department of health and human services, office of the inspector general
(OIG), Balanced Budget Act of 1997, health insurance portability and accountability act offices
and external auditors. External auditors are very important in monitoring compliance in the
organization. Therefore, they are always in touch with the HIM in terms of carrying out audits
and monitoring to find out where there is discrepancies and alerting the HIM. The OIG is a body
that sets the compliance standards and requires that all organization comply with these rules.
Therefore, the HIM must report to the office on how it is ensuring that there is compliance in its
operation. Likewise, the HIPAA act and the balance budget act also are bodies that have the
responsibilities of ensuring that the health organization compliance with their set standards.
Therefore, HIM is always in links with these agencies and briefing them on how the organization
is handling its activities (Prophet, 1998).
Dissemination of information
Information is disseminated through various channels. One of the ways the information
about health organization is transmitted to the agencies is through hotline. HIM is able to get in
touch with the officers in these agencies and brief them on how they are faring on. They also
communicate through emails, fax, and mobile among other means. In some occasion, agencies

send their field officers to visit the organizations and brief the HIM on various issues of
Guideline for implementing the plan
This plan must be well implemented to ensure that the objectives desired are attained.
Various elements must be included in the policies to ensure that the plan is successful
Elements to be included in the policies
One of the important elements when creating compliance policies is education and
training requirements. HIM personnel require to have specialized education and training
qualifications to enable them carryout their functions well. They should be creative, have
management and leadership skills, be good communicators, be honest and be of high integrity to
exercise their responsibilities in a professional manner. The coding and the billing personnel’s
equally should be competitive to executive their roles with diligent. Employees and all
stakeholders require continuous training. Training should be comprehensive and should cover
general areas of compliance and specific policies and procedures.
Other elements to be included in the policies included a process for reporting any
instances of potential or actual violation. A good operational process that identifies coding errors
should also be in place to ensure that there are no errors that are made in the coding process and
in implementation of the policies.
There should be open communication channels in the organization to ensure that policies
are well implemented. Communication is paramount in ensuring that the organization performs
better and achieves the set objectives. The plans can only be achieved if there is smooth

communication and coordination in the organization. It is also important to have a disciplinary
action procedures and guidelines to institute punishment to those employees or any other
stakeholders that does not support or work towards the realization of the set policies in the plan.
Monitoring of coding accuracy
Coding is very important and therefore it should always be monitored to ensure that
information provided is the right information. This is so because; any information that is not
correct may lead to greater impacts on the organization. Some of the challenges that Juliette will
have to deal with in her new role include, wrong billing or double billing, inappropriate billing
and wrongful coding among others (Prophet, 1998). Therefore, continuous monitoring will be
required to ensure that such mistakes that relates to coding are dealt with appropriately. As the
Health Information Manager, Juliette will have to come up with strategies that will ensure that
such information is not repeated. One of the ways is to recruit qualified employees who have
high level of integrity. The staffs should also be trained on the way they need to carry out their
responsibilities on continuous basis to minimize such errors. The accuracy of the coding can
also be monitored through continuous review of the data. This will allow the HIM to find out
such mistakes. The organization can also use the services of both internal auditors and external
auditors to monitor how the coding is done. They should submit reports on the way the process
of coding is being carried out to help ensure that the information that is entered in the system is
Process of reporting noncompliance internally
There are circumstances where employees will not comply with the set standards. It is
imperative that an internal system is developed to ensure that such issues are well reported. One

of the ways noncompliance can be reported is by setting up a box where employees or any other
stakeholders can write their comments and drop them in the box. This will help to find ways of
solving such cases. Furthermore, the organization can have a small office where, employees are
able to visit and report any scenario of noncompliance. Such employees should be given
immunity or protection from any form of victimization by the organization.
Corrective action plan incase of non compliance
In case of noncompliance, the stipulated rules should be used as a guide in solving the
problem ensuring that the systems work normal. The compliance committee should be convened
to help with ideas and guidance on the appropriate steps. In some cases, if the rate of
noncompliance is extraneous, then the organization is held responsible by the federal or state
Course of action if external audit identifies coding noncompliance
In case an external auditor identifies coding noncompliance, this information must be
relied to HIM for a course of action. The auditor needs to compile a repot stating clearly, where
the problem was and the magnitude of the problem. The report then is forwarded to the health
information management who will take the next step of action (Prophet, 1998). For instance,
HIM can form another HIM professional to review the records to verify the existence of the
coding problem, notify the compliance committee to find out the source of the problem. Legal
counsel may be consulted and the problem may be reported to the payer according to the advice
give. In addition, audit will then be carried out after few months to ensure that the problem is
Evaluation of the plan

Evaluation is important because it help to determine whether the plan or the step of
actions taken or implemented worked as indented. It therefore helps to change tactics or to
improve on what has already been set. The plan should be evaluated by analyzing whether the
various plans that were set were all achieved. For instance, to determine whether, employees are
trained and have competent, it will be determined on how they carryout their tasks and on the
number of mistakes in the coding. The disciplinary action taken on employees will also help to
evaluate the effectiveness of the plan. Health information management will carry out evaluation
or an external agent to ensure that there is no biasness.
Elements of coding compliance-training program
Training program on elements of coding is essential to ensuring that all employees are
informed of what they are not supposed to do. The training program will entail training on
appropriate coding and billing practices, on multiple reimbursement systems, on standards,
policies and requirements pertaining to clinical documentation, billing and coding, third party
payer requirements, interpretation of legal requirements interpersonal and strong analytical skills
among others.
Identification of needs
Training needs of employees will vary among employees in the organization. Therefore,
identification of these needs is essential in providing appropriate training. The needs will be
identified based on the responsibilities of every employee. Those employees that have higher
responsibilities will be given priority in training as opposed to those with less and simple duties.
To ensure that training is effective, all employees will be trained based on their responsibilities.
They will be trained on how to carry out their responsibility well and ensure that they comply

with the set standards. The training will be carried out in the organization as well as through
exchange programs as the need may be. These training will be done on continuous basis as need
may arise to update employees and ensure that they remain competent.
Evaluation of training program
To ensure that the training program is effective, evaluation will be done. This evaluation
will be done based on the output of employees after the training. They will be expected to
improve in their services. For instance disciplinary actions is expected to decrease, cases of
noncompliance should also be reduced.



AHIMA (2013). Practice brief: seven steps to corporate compliance: The HIM role
Bryant, G. (2007). POA Indicator Compliance…Is Your Hospital and Coding Staff Ready?,
Journal of Health Care Compliance, 9(5):21-26.

Department of Health and Human Services. (2009). “Compliance Program Guidance for Third-
Party Medical Billing Companies.” Available at: .

Prophet, S. (1998). Health Information Management Compliance—A Model Program for
Healthcare Organizations. Chicago, IL: AHIMA.