Healthcare compliance and coding management effectiveness

Healthcare compliance and coding management effectiveness

BBT Task 1

There are several job functions of the current staff as presented in the scenario. These
include (i) coders/nursing staff: there are 3 coders and each one of them performs inpatient
coding services. One of the coders also performs coding services for a physician who treats
patients within a small outpatient center attached to the hospital. (ii) A front office employee:
there is also a front-end employee at the hospital.
The various concepts and processes behind: Code look-up software – This is a
software solution that offers the medical coding professional a full suite of coding tools that
include CPT code lookup, diagnosis codes, Correct Coding Initiative resources, as well as
built-in references on all medical coding specialties. It is a web-based package that does not
require any software installation. It is best for busy hospitals that need a streamlined medical
coding solution, and remote medical coders who work from home (Krauss, 2010). Encoder
software: This is basically a software program which converts information from one code or
format to another for a particular purpose. This software brings diagnosis codes which would
be difficult to manage by using code books only. It is a web-based code look-up tool for
several code sets including CPT, ICD-9-CM, HCPCS and ICD-10. In essence, EncoderPro
software searches these medical code sets to increase accurateness and allow ease of auditing
for compliance (Young, 2008). Charge Description Master (CDM) table or simply charge
master is essentially a complete listing of items which can be billed to a payer, patient or
healthcare provider. It is a master table file which has the essential elements for pricing,
coding and identifying any item which might be provided to patients including supplies,


services and procedures. It is of note that the charging of these items for the patient’s bill is
managed using Charge Description Master table (Cedars-Sinai, 2014).
I would determine job functions needed at both the hospital and the clinic by
responding to the following imperative questions: does the job exist to do this particular
function? What are the minimum job standards and qualifications? On a weekly basis, how
much time is spent in performing this function? What essential training, experience,
education, and skills are required? What are the mental and physical aspects of this function?
What equipment are utilized in doing this function, and how frequently is the equipment
utilized? If this function were not performed, would there be major consequences? Did the
prior worker perform this function? Do employees in the same positions perform this
function? Is this function indispensable as opposed to unimportant? (Herschman & Barry,
A plan for recruiting and hiring encompasses the following: (i) developing accurate
job descriptions; (ii) compiling a success profile; (iii) drafting the advert that describes the
position along with the major qualifications needed; (iv) posting the job advert in the
mediums that are most likely to reach the prospective candidates for the job. (v) Developing a
series of phone-screening questions; (vi) reviewing the received resumes and identifying the
best candidate; (vii) screen candidates by phone and select candidates for assessment; (viii)
assessing the prospective candidates for their attributes and skills with the use of a proven
assessment tool. (ix) Scheduling and conducting interviews; (x) selecting the candidate; (xi)
running a background check on the selected candidate to uncover any possible problems not
disclosed by prior testing and interviews; (xii) making my offer to the candidate. Retaining
the employees will entail the use of various programs such as perk programs, incentive
programs, healthcare programs, and offering flextime and telecommuting options.


During the planning process, people who may be helpful include the person in charge
of human resources, as well as the current employees of the organization. During this
planning process, the challenge faced would be resistance from the current employees who
would think that they might lose their jobs. I will address this challenge by informing them
how the plan will benefit them and assuring that even if they lose their jobs, I would help
them find jobs in other organizations. There are a number of concerns related to productivity
and quality standards as presented in the scenario. I would identify these concerns by talking
with the patients, Chief Financial Officer, as well as with the other employees of the
organization about the concerns as asking them to tell me the concerns. I would address the
identified concerns by using my skills and knowledge regarding how to solve the problem. I
would also ask the people affected for their input on how the concern should be addressed.

BBT Task 2

The necessary components of the HIM compliance plan include: (i) UHDDS
Definitions: inpatient procedures and diagnoses would be coded in accordance with Uniform
Hospital Data Set (UHDDS) definitions for principle and extra procedures as stated in the
American Hospital Association’s Official Guidelines for Coding and Reporting. Coders
would be responsible for this component (Ossoff, Braswell & Raborn, 2012). (ii) Reportable
diagnoses and procedures: to attain uniformity in the coding of procedures and diagnoses,
coders have to observe all official guidelines for coding as specified in this plan; and have to
methodically assess the whole health record as part of the coding process so as to assign and
report codes that are the most appropriate. (iii) Query process: the physician has to be queried
as soon as a procedure or diagnosis has been established to meet the reporting guidelines, or
when conflicting, ambiguous or questionable documentation is present. The query process
could be documented on a retrospective or concurrent basis. Coders are responsible for this
process. (iv) Coding summary: Face sheet or a coding summary shall be placed in the health


record of each inpatient discharge, observation admissions and same data surgery. Coders and
physicians are responsible for this component (Rinkle & Boerner, 2013).
The HIM would be linked with 3 external agencies that would monitor compliance.
These agencies are: Office of Inspector General (OIG); Coding Compliance Workgroup; and
Compliance Officer. These agencies disseminate information by keeping close contact with
the organization and ensuring that the plan is adequate (Young, 2008). The elements to be
included in the policies within the plan include: (i) how HIM coding should be – compliant,
accurate, consistent and complete. (ii) How employees will maintain ethical standards in the
performance of coding procedures; (iii) training and orientation of employees; (iv) where one
can seek guidance regarding any questions or uncertainties about the plan; and (v) unethical
and prohibited conduct relating to coding and billing.
Coding accuracy would be monitored by using an effective coding internal quality
monitoring process for every coder and results would be compiled and then reported to the
Compliance Officer. The processes for reporting noncompliance internally will essentially
entail immediately reporting to a supervisor who will then take the appropriate action against
the individual who did not comply. In circumstances of noncompliance, a corrective action
plan entails subjecting the employee to suitable performance management pursuant to every
pertinent procedures and policies, up to and including dismissal. The action would be
corrected immediately. If external audit identifies coding noncompliance, the course of action
is to make corrections as soon as possible, and taking the appropriate measures to ensure total
compliance in future (Krauss, 2010).
The plan would be evaluated by the external coding auditors, along with the hospital
HIM director and the hospital’s administration. The plan should be evaluated by assessing
whether or not it has achieved its intended purpose and how effective it has been. In regards


to the coding compliance training program, needs would be identified first by specifying who
needs the training, why and in what way do they utilize coding. In essence, all HIM coders
would be required to finish coursework for ICD-10-CM/PCS preparation (). All billers and
coders would receive training and orientation in essential procedures needed for maintaining
integrity and accurateness of coding and billing. Continuing education would be offered
using inservice, journals, memos, handouts, as well as formal education as available and
approved. Each biller and coder would receive training in coding, documentation and billing
compliance issues yearly or more often as need arises. The coordination of the training would
be done by the Coding and Reimbursement Compliance Workgroup in addition to, or
together with training offered by the Compliance Program (Rinkle & Boerner, 2013).
The HIM Coders along with other appropriate workers must complete training
activities. Coders might be needed to complete other educational activities occasionally as
directed by the Compliance Officer. The training should be evaluated by appraising how
effective and successful it has been. For instance by the number of employees who
successfully completed the program. It should also be evaluated by assessing the job
performance of employees who went through the training program; if they are doing their
coding and billing functions well, then the training program was effective, otherwise, it was
not (Ossoff, Braswell & Raborn, 2012).




Cedars-Sinai. (2012). Charge Description Master (CDM).
Herschman, G. W., Barry, J. D. (2013). Preparing Compliance Program Effectiveness
Reports. Journal of Health Care Compliance, 15(6), 15-34.
Krauss, G. (2010). A Fresh Look at Coding Compliance. Journal of Health Care
Compliance, 6(1), 18-21.
Ossoff, R. H., Braswell, L., & Raborn, M. (2012). The Value and Role Professional Coders
Play In Health Care Compliance. Journal of Health Care Compliance, 14(3), 51-52.
Rinkle, V. A., & Boerner, C. M. (2013). ICD-10 and Compliance — Joined at the Right Hip
0SG90ZZ?. Journal of Health Care Compliance, 15(5), 5-62.
Young, C. (2008). Billing and Coding Laboratory Developed Tests. Journal of Health Care
Compliance, 10(2), 69-72.

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