Healthcare Compliance and Coding Management Effectiveness

Healthcare Compliance and Coding Management Effectiveness

Use the Healthcare Compliance and Coding Management Effectiveness Scenario below to complete the following assignment:

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

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:

1. Describe elements to be included in the policies within the plan.

2. Explain how coding accuracy will be monitored.

3. Discuss processes for reporting noncompliance internally.

4. Explain a corrective action plan in circumstances of noncompliance.

5. Describe the course of action if external audit identifies coding noncompliance.

6. 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:

1. Explain how needs would be identified.

2. Describe the who/what/when/where of the training program on a brief sample agenda for training.

3. Explain how the training program should be evaluated.

D. When you use sources, include all in-text citations and references in APA format.

Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the General Instructions section.Include web links for all sources

Healthcare Compliance and Coding Management Effectiveness Scenario

The city of Midlothian had a population of approximately 57,000 residents and two hospitals that had served the community for generations. The community was not pleased when the hospitalschief executive officers held a joint news conference to announce that the hospitals were merging. Most people liked having choices for their healthcare, and they believed the merger would impact their right to choices in services. There had been rumors circulating within both organizations for months, but now that the news had become official, staff was concerned about downsizing and their future employment.

Juliette was the health information management (HIM) department manager of the larger of the two hospitals and found herself called to the office of the chief financial officer (CFO) several days after the merger was announced. The CFO explained that there would be staff cutbacks because of the merger. Juliettes face betrayed her worst fears, showing she thought she was losing her job. Her expression made the CFO smile. Leaning forward, the CFO told Juliette administration wanted her to assume management of all HIM personnel from both facilities, as the reorganization moved forward.

Her role in the merger and reorganization would be an important one. The expectation was that within six months she would reorganize the staff from both HIM departments into one unit, restructuring departmental functions for efficiency and greater effectiveness.

Juliette was delighted to take on the challenge and thanked the CFO for the opportunity but the CFO had more to say. There had been several coding compliance problems that occurred over the past 18 months at the smaller hospital, and the CFO directed Juliette to meet with the compliance officer from the smaller hospital to discuss the specifics of these issues. It was important to administration to address any concerns as this change was occurring so as to facilitate better practices and processes. Administration was aware of public concerns about services, and they were carefully selecting a management team to meet any challenges directly and effectively.

They needed Juliettes expertise in HIM to identify the root of the problems and prevent them from happening again. Several of the issues were as follows.

One of the primary care providers visits a rural outpatient clinic twice monthly and treats between 15 and 20 patients each visit. The outpatient clinic billing department performs the coding and billing functions for the patients he treats at the outreach site. Recently, the nurses at the hospital office in Midlothian have been receiving calls from patients, where they have been questioning numerous bills. Patients are being billed twice for the same services at the outpatient clinic. Juliette needs to investigate why this is occurring and solve the problem.

A hospital oncologist spends Friday afternoons seeing patients at a VA hospital about 100 miles away. Two nurses work in the oncologists office, administering chemotherapy. Patients are billed for chemotherapy treatments at the same rate for each of their treatments. Most of the patients are seen Monday, Wednesday, and Friday for their treatments. A nurse who is new to the oncology floor at the hospital has questioned if this billing is appropriate.

Through internal audits, it was found that one of the cardiologists had unusually high E/M levels. Documentation revealed the patients who were coded at a higher level were being seen on the same date of service by the social worker.

Through internal audits, it was found that one of the urologists had unusually low E/M levels. The urologists nurses complain the urologist is always behind schedule because of all the time spent with patients.

The CFO explained to Juliette that her immediate goals for the new HIM department should include the initial development of an HIM compliance plan, which would be in alignment with the hospitals compliance plan. Since the organizations were merging, she would need to meet with both current compliance officers to obtain an overview of their goals and to begin to develop the elements of the HIM compliance plan. At this point, administration is unsure which officer will remain. They will be evaluating both officers for their ability to manage the merger events, and they will make their choice within a few months.

Administration expected the HIM compliance plan to focus on coding compliance and standards required by external agencies. It would include internal processes within the daily workflow to minimize risks and include a detailed audit process. Juliette would be expected to review current guidelines for how noncompliance incidents are addressed and review the current process for confidential reporting of concerns to determine its effectiveness.

Policies and procedures documents would be written, approved, and implemented. Staff would receive initial education, and Juliette would be expected to develop a method for ongoing training. She would need to immediately focus on identifying deficiencies in coding skills and implement training to bring the competencies of all coders to appropriate levels.

The CFO stood, indicating the meeting was nearing completion. The CFO shook Juliettes hand and summed up their discussion. Juliette was being offered a leadership position in moving the HIM department and staff forward as the hospitals merged their services. There were three areas for immediate focus.

The first was to identify the root causes of the coding compliance issues that were reported to her and to develop workable solutions. The second was gathering information on the components of an HIM compliance program and beginning to lay the foundation for its implementation. Finally, as she was discerning current problems and developing plans for the HIM compliance program, she needed to assemble a HIM workforce comprised of the best and the brightest personnel both facilities had to offer.


Inherently, coding compliance is linked to several previous compliance risk areas such as accurate billing, proper documentation, retention and creation of medical records, teaching physician rules, and referral guidelines. An effective compliance plan should encompass an efficient coding compliance plan.  

Healthcare Compliance and Coding Management Effectiveness


             In any institution, it is essential to have a compliance plan to ensure that all the activities are well documented to enhance achievement of the objectives or goals of the organization. Coding management becomes an important area too towards achievement of the goals of the entity. This paper addresses various aspects relating to compliance planning and coding management based on a case study involving a merger of two health facilities. The major areas of discussion are on HIM compliance plan emphasizing on the coding function, guidelines for implementing the plan and discussions on plan evaluation.

A. HIM compliance plan that emphasizes the coding function

Following the merger, Juliette will need to develop a HIM compliance plan that includes all personnel that are accountable for billing, documenting, performing, monitoring, supervising, recommending, approving, or maintaining billing or coding processes or procedures (Wu et al., 2006). The compliance plan will consist of various standards, procedure, and policies aimed at identifying and defining regulations and laws, correcting the identified challenges, and putting controls in place so as to prevent future problems (Berg, 2003). Inherently, coding compliance is linked to several previous compliance risk areas such as accurate billing, proper documentation, retention and creation of medical records, teaching physician rules, and referral guidelines. An effective compliance plan should encompass an efficient coding compliance plan.

Components of the plan

The HIM coding compliance plan will mainly focus on ensuring the claims received by Medicare are complete and accurate. The five essential components in the compliance plan include detection, correction, prevention, verification and comparison. The components are essential in ensuring that the HIM programmes in unison run smoothly.

Detecting potent coding compliance challenges necessitates ongoing coding monitoring for completeness and accuracy. Monitoring is through performing a random chart audit on some samples of the records. A computer system can monitor the coding compliance in the following dimensions; coding, clinical, and resource.  Corrections can also be done when issues arise. Coding changes are possible after an HIM professional makes a review. The chart audit should be performed before billing to prevent resubmissions and complains from clients, which may lead to external audits from external agencies (Brown, 1998).  Billing delays should also be avoided since they are costly. Hence, the chart audit correction procedure should be carried out in a timely and highly targeted manner. Another component is prevention where worksheets produced during computerized audit have a vivid text elaboration of the potent coding compliance problem’s nature and record recording’s suggestions. There should be clear identification of the ICD-9-CM coding rules. These measures prevent future recurrences of such problems.

The fourth component is verification that involves verifying that the correction, detection, and prevention functions are performed actively. In this regard, a comprehensive and summative audit trail of coding compliance- related deeds and code changes should be maintained for verifications. There should be three complete codes sets for every admission; original, billed, and post-billed version. Through this, the hospital will be able to minimize reports related to the documentation of the process’s results. The database should also maintain a record of the code changes’ nature. Hence, the patterns of problems will be identified easily and a corrective action taken (Berg, 2003).

 Last component is comparison, which is the benchmark towards external coding norms. Through this, a hospital can know how its coding practices match up to those of other hospitals. The other four components discussed have introspective functions; internal evaluation.

Responsibilities of the staff who implement each component of the plan

            Compliance officer is the one required to implement the various components of the plan.  The officer is an appointee of the Board of Directors or Physician leader and reports to the Executive Committee. The officer performs different roles including 1) Implementing and monitoring the compliance program, 2) Report regularly to the Executive Committee and the Compliance Committee of the practice in regard to the implementation’s progress. He also assist the governing authorities in establishing the mechanisms for improving quality of services and practice’s efficiency and to reduce potent vulnerabilities to waste, abuse, and fraud, 3) Revise the program periodically based on changes in the hospital’s needs and governmental guidance (Wu et al., 2006). Other responsibilities are 4) Participating and developing training and educational programs based on the program’s elements and ensure that all employees are in compliance, 5) Ensure independent agents and contractors are aware about the program’s requirements in regard to billing, marketing, and coding, 6) Coordinate personal issues with departmental heads. The officer also 7) Assist the management and Practice Administrator monitoring activities and coordinating internal conformity reviews (Brown, 1998), 8) Investigating and acting on matters related to compliance, 9) Developing programs, procedures, and policies through which employees can detect fraud (Stevenson et al., 2008) and 10) Reviewing all relevant documents.

The compliance committee consists of the Practice Administrator, general counsel, a physician chosen by the Executive Committee, and other personnel that the Board of Directors appoints and the Executive Committee approves. The committee perform different roles including 1) Analyzing the legal requirements, organization’s environment and particular risk areas, 2) Assessing existing procedures and policies that address particular risk areas for inclusion in the compliance program, 3) Monitoring and recommending the practice of the program by all departments in the daily operations. Other roles include 4) Collaborating with relevant departments to come up with conduct standards and procedures and policies to promote the plan, 5) Promoting the plan and detecting potent violations (Berg, 2003) and lastly creating a system for responding to, evaluating, and soliciting problems and complains.

The link between HIM and three external agencies that monitor compliance

            Various external agencies monitor compliance and therefore work together   with HIM to ensure that operations comply with various laws and standards. One of the agencies is AHIMA. The agency can be used as an external auditor. Moreover, it offers tools, resources, and the knowledge required to advance professional standards and practice for health care delivery. It can solve critical HIM issues and answer any questions on HIM. It allows networking between HIM professionals and communities can interact, engage, and share information. The organization discusses various useful topics and organizes events and conferences. HIM professionals will therefore benefit from the recommendations and the resources that are offered by AHIMA in ensuring that they focus on their objectives. For instance, from the events that are organized HIM professional will have to learn new approaches and trends about law and new standards in coding and management of information. Another agency that can function as an external auditor is t he Office of Civil Rights as its major goal is protecting patients from discrimination while receiving health care. Some of these mistakes can be discovered through allowing the organization to audit or after a patient files a complaint. It protects patients’ health information privacy. HIM will use information collected by the Civil Right Office from their offices and websites pertaining to instances where their were bad practices and come up with appropriate measures to avoid the same occurring. The information is useful in enhancing the provision of healthcare in the facility. The last agency is Blue Cross Blue Shield Association, an organization whose main role is offering health insurance. The organization also administers Medicare in many regions and states and as well can function as an external auditor. The organization communicates through events and conferences.  HIM professional will use the information from Blue Cross Blue Shield Association to determine the patients that have a health cover and those without.  Therefore, they will use the information to find out whether it rhymes with that of the company to ensure that they keep track of any defaults and balances that the patient’s own the hospital. Therefore, it will help either in ensuring compliance hence reducing the number of complaints from the company or from the patients.

The main aim of external auditors is detecting coder errors (Brown, 1998). These agencies will therefore help HIM to identify the errors through monitoring the compliance at the hospital. The compliance officers should expertise in state and federal health care statutes, requirements for health care programs in federals, and regulations (Stevenson et al., 2008). The external agencies must be guided by policy that guides their external reporting procedures to ensure consistency. HIM also must also conduct regular audits to identify any deficiencies and seal loopholes that might have gone unnoticed by internal auditors.

Dissemination of information by the agency  

            Dissemination of information between the agencies and HIM should be well defined to ensure that their s no misunderstanding and distortion. The three agencies must establish an appropriate channel that they will liaise with HIM in case of detection of code errors or any issue pertaining their operations. Confidential information should not be disclosed and be should be conveyed within stipulated time to avoid inconveniences. The most appropriate channels of disseminating information is through reports on their findings.  The reports should be formal and duly signed to enhance the authority or the credibility. Other ways to disseminate information is through memos and letter (Brown, 1998).

B. Guidelines for implementing this plan

Elements requiring inclusion in the plan

            Various elements are included in the plan to ensure that compliance program becomes effective. These elements include 1) Designation of a compliance committee and officer who will oversee the running of the program. The officer maintains and creates effective communication lines with all employees. This will include a reporting system and encouraging complaints, questions, and suggestions (Stevenson et al., 2008), 2) Retention and creation of a records system that ensures accurate and complete medical record documentation, procedures and policies, and privacy concerns, 3) Conducting effective education and training based on the identified needs.  Other elements are 4) Employee performance consisting of key element; compliance. All employees will be required to adhere to and promote compliance, 5) Well-publicized disciplinary guidelines used to enforce the standards. The consequences for violating standards of conduct and the procedures for handling disciplinary problems will be set out, 6)Internal monitoring and auditing (Westra, Solomon & Ashley, 2009), 7) Detected offenses will be responded to and corrective action initiatives developed. If there is noncompliance, immediate investigations will be initiated and corrective actions such as returning overpayment, and referral to civil or criminal law authorities will follow, 8) The compliance program will be assessed for effectiveness periodically and 10) There will also be written compliance policies, procedures, standards, and practices to guide the employees and the hospital on a daily basis. This will include a code of conduct.

Monitoring coding accuracy

            The merger’s compliance office will develop a process for ongoing evaluation. This will entail monitoring the implementation of the plan thoroughly as well as regular reporting. Ongoing monitoring will involve generation of compliance reports that includes suspected non-compliance reports. The compliance officer will maintain these reports in the compliance files and share their details with the compliance committee (Wu et al., 2006). This process will adhere to the existing legal guidelines as directed by the merger. Some of the techniques that will be used during monitoring will involve sampling protocols, which will enable the compliance officer to detect and review all the variations from a recognized baseline. If there are significant baseline variations, a reasonable inquiry will be set up to assess the deviation’s cause.This will ensure that transparency is a guiding principle in the merger. After this merger, HIM is required to carryout comprehensive audits from internal and external auditors. All the sections need thorough scrutiny to identify errors to promote consistency and accuracy. The institution should also consider automated means, which makes identification of inconsistent and inaccurate coding easier.  The most important thing is to ensure that various systems are checked to find out whether they are functioning appropriately as expected trough reviews (Becker, 2010). 

 Processes for reporting noncompliance internally

In case there is information on potential misconduct or violations, the compliance offer is responsible of conducting investigations. An investigation that is conducted internally will involve interviews and reviewing billings, medical records, and all relevant documents (Westra, Solomon & Ashley, 2009).  To ensure protections from coerced information disclosure following the investigative interviews, a qualified legal counsel will conduct the investigation (Berg, 2003). The client privilege will be protected in case other agencies demand to know the information about the internal investigation. It is worth emphasizing that if misconduct is detected, it should be identified if it was willful of negligence. If the person that was involved in the misconduct is not an employee of the hospital, the compliance committee will forward the findings to a proper department chief (Stevenson et al., 2008).

In cases of inadvertent or negligence conducts, the case will he handled by the proper supervisor. The supervisor is supposed to inform the compliance officer about the offence and a corrective action taken to ensure that the problem is solved. If after reasonable inquiry the compliance committee and officer believe there is a misconduct that violates administrative, civil, or criminal law, the misconduct should be reported to a government authority within sixty days (Wu et al., 2006).

A corrective action plan in circumstances of noncompliance

If the inquiry identifies that the deviation was as a result of legitimate reasons, then the practice will take no corrective or limited action (Brown, 1998). In case it is determined that the deviation was as a result of misunderstanding the rules, improper procedures, systemic problems, and fraud, the practice will engage in prompt steps to ensure that the problem is corrected. Overpayments that result from these deviations will be returned to the affected payor promptly together with proper documentation.

All individuals who do not comply with obligations will face disciplinary actions. In a person is not satisfied with the corrective action the supervisor gives, he can appeal to the compliance officer within a span of ten days. Following discussion, the compliance officer can modify or affirm the corrective action (Westra, Solomon & Ashley, 2009). Proper corrective actions are determined based on individual cases. Reckless and intentional noncompliance can subject the transgressors to crucial sanctions including oral warnings of possible suspension, financial penalties, termination, or privilege revocation. Some disciplinary actions may he handled by the department manager and others by the senior hospital administrator.
The course of action if external audit identifies coding noncompliance

The external auditor reports the investigation’s results to the compliance officer. In turn, the compliance officer reports to the compliance program medical director as well as the compliance office leadership. These top managements discuss and come up with a proper corrective action for all the involved personnel.
Evaluating the plan

A coding compliance program should be evaluated and reevaluated continually. This is based on the fact that rules always change, codes changes, novel reimbursement methodologies may be adopted, there are employee turnovers, and new laws may be enacted. A compliance plan’s effectiveness can be determined through a compliance scorecard (Stevenson et al., 2008). The scorecard measures particular processes and acts as a tool for motivation for managers and employees. The program is evaluated by the administration and staff where they review and approve the scorecard items, problems should be identified and solved and the performance in one area should not be used to judge the effectiveness of the entire program (Berg, 2003). Some scorecard items are as follows; a 95% coding accuracy goal, reduced claim or billing errors, 100% participation in documentation and coding educational programs, and attainment of essential continuing education units by all coding staff.
C. The elements of a coding compliance training program
Identifying the needs

The needs of a coding compliance training program vary depending on the institution’s needs and if the employees are existing or new. There should be an annual assessment of educational needs (Stevenson et al., 2008). Training should be pegged on immediate need/short term and long term.  Just in time training is essential to eliminate unintentional coding errors and when addressing changing regulations and coding errors. The cost of training is also an element requiring consideration in coding compliance-training program. For instance, On-site continuing education can be offered to coding staff so that they can maintain costs effectively and coding certification conveniently (Safian, 2009).  In reference to this scenario, the HIM must identify whether the staffs require more training, the costs, and availability of the resources.  For instance, in the case the HIM wants to minimize errors, the staffs will be required to undergo training on the coding practices.

The who/what/when/where of the training program on a brief sample agenda for training

Since the merger will result to a large facility, classes will be scheduled regularly on topics which involve high risk areas or are typically complex. Convenient classes will be offered during work hours to ensure that coders acquire necessary education. Through such classes, certified coders can get CEUs and indicates the hospital’s dedication to compliant coding. It is advisable for the coders to gather in a ‘roundtable’ format so as to be able to discuss real-life examples of coding with the peers. Sessions on clinical topics can assist specialty coders in gaining insight about complex procedures. Anatomy classes can assist gynecologists, orthopedics, radiologists, and cardiologists (Berg, 2003). Topics can include issues identified from audits and reviews.

There can be extended educational programs for some topics after which there are exams. Just-in-time-training meets immediate educational needs, addresses recent coding errors or regulatory requirements that are changing constantly, and helps new employees to prevent unintentional coding errors. All education should be documented well and the attendees’ names, length, topic, and date should be noted. The coding management is responsible of offering the education.
3. Evaluating the training program

             Evaluation is important to determine whether the objectives of the training programs were met or not. There are various premises that organizations use to evaluate   whether they have achieved the goals or not. In this case, the evaluation geared to establish whether indeed the problems that occurred earlier such as double billing are eliminated. The employees must therefore, be equipped with requisite skills and knowledge to ensure that they do not make such errors. Kirkpatrick’s four levels model can also be used to evaluate the training programme. This model categories evaluation into four levels including reaction, learning, behavior and results. Reaction is aimed at measuring whether the training program had impact or note. This is done by designing a form to quantify the employees’ reactions, developing acceptance stands and measuring reactions against standards and taking the appropriate action (Employment Security Department, 2014). Learning aims to find out whether the training contributed to the extend that the attitude of the participants as changed. This therefore aims to find out the knowledge leaned, skills developed or improved and attitudes changed.     Evaluation is also aimed at determination the extent to which a change of behavior has occurred. This can be evaluated by interviewing some of the trainees, immediate supervisors, and subordinate, evaluating both before and after the program, and considering costs versus benefits.  Results level aims at measuring the results that has occurred as a result of the training. This improvement can be in terms of the increased productivity, reduced errors and work quality. Likewise, hiss can be evaluated through measuring the level of errors both before and after the programs.


Becker, J. (2010). Guide to Coding Compliance. Clifton Park, NY: Delmar Cengage Learning. ISBN: 139781111185152.

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