Healthcare Compliance and Coding Management

Read the attached “Healthcare Compliance and Coding Management Effectiveness
Scenario,” (File Attachment)which describes several problems you might face as a newly
hired health information management (HIM) department manager. This task will help you
to think through the process of determining which types of coding functions are necessary
for the HIM department. It will also help you in evaluating staff qualifications for hiring or
downsizing purposes. The scenario also encourages you to consider the HIM workflow
along with departmental quality and productivity concerns, which may influence decision
A. Discuss how you would systematically proceed with the challenges presented in the

  1. Analyze the various job functions of the current staff.
  2. Analyze the various concepts and processes behind each of the following:
    a. Code look-up software
    b. Encoder software
    c. Charge description master table
  3. Explain how you would determine job functions needed at both the hospital and the new
  4. Discuss how you would structure a plan for recruiting, hiring, and retaining staff in both
    a. Identify others in the organization who may be helpful to your planning.
    b. Describe how challenges you may encounter during this planning process could be
    B. Discuss concerns related to productivity and quality standards as presented in the
  5. Explain how you would identify these concerns.
  6. Explain how you would address the concerns you identified.
    C. If you use sources, include all in-text citations and references in APA format.STOP

Healthcare Compliance and Coding Management

Scenario Challenges

The main challenges that I am facing as the new supervisor for health information systems in this
rural hospital are rooted in directives that I have received from the hospital’s Chief finance
Officer. First and foremost, I have the challenge of how to go about letting go of one of the
coders that have been stationed at this hospital. Secondly I have to figure out what to do about
the front office employee who six months after the installation of the new electronic system. His
position poses a challenge because he is still doing things the manual way and also seems to be
engaged in a variety of activities, in short, his position in the organization is not well defined.

The rest of the staff is now getting worried about the security of their jobs given the talk of the
hospital acquiring another clinic that has a large number of nurses and other hospital personnel. I
therefore have to find a way of coming up with an amicable solution to the management of the
two facilities.

An analysis of the current staff’s job functions

The hospital currently has one Chief Financial Officer. The role of this employee is to oversee all
of the hospital’s fund management activities. This includes the budgetary allocation that different
departments in the hospital receive. Another role of the Chief Financial Officer is to ensure the
hospital is running in a financially sustainable method. This means that this individual seeks to
ensure there is some level of balance between the hospital’s income and expenses. Most
importantly, The Chief financial officer has the work of keeping the management of the hospital

abreast with different measures being taken by the finance department as well as provide them
with advice on how to comply with different financial actions taking place at the hospital.

The hospital also has three coders whose task is to insert the patient’s medical data into the
system. One of them however does the same task for patients who get healthcare services from a
physician who is stationed at one of the hospital’s smaller outpatient centres.

There is also one front office employee who has a wide range of tasks that change with the
prevailing need. The main activities this employee is involved in includes the answering of
phone calls, handling online requests, the filing and retrieval of patient records as requested by
the hospital’s various departments, releasing information and also offering assistance to those
who walk in to the hospital for either treatment or visits.

At the clinic that the hospital intends to purchase, there is another front office employee whose
roles and skills seem to be more advanced than the one in currently employed at the hospital.
This person does the coding of patient data as well as billing. At the same time, this employee is
furthering his education by studying to become a registered health information technician. This
other facility also has in its workforce a number of long-term employees and nurses.

An Analysis of several technical terms

Code Look up software

This is a collective term for computer applications that are installed in hospital with the purpose
of assisting in the billing of patients for the different services they receive in the hospital. This is
a digital solution cum replacement to the tedious process of manually going through the
hospital’s procedural codebooks (3M, 2013).

The procedure of operating this software involves the coder inserting values that coincide with
the different medical procedures that have been carried out on a patient. Depending on the
assigned or pre-set values that are stored in the system, a report is generated displaying a
summary of the services that have been rendered as well as their respective corresponding
charges as well as a sum total at the bottom of the report.

The figure indicated can either be paid for by the patient who is not covered or more likely be
sent through an invoice to the patient’s Medicare insurance provider. In this case, it gets sent
electronically and a copy is also printed out for the patient to append his or her signature.

Encoder Software

This is a collective term for applications that are used to set the values and parameters to be used
in the code look up software. This software basically determines the types of medical procedures
that can be offered in a given healthcare facility as well as the corresponding charge that the
hospital chooses to levy. Encoder software is used to ensure the present code lookup software in
use is up to date and also in alignment with standards that have been set internally in the hospital
as well as externally through government initiative and healthcare bodies. The encoding software
is also used to endure consistency of the data processed and provided by the code look up

Charge Description Master Table

The charge description master table is also called the chargemaster and it is a comprehensive list
that contains all items billable to a hospital’s patients for medical services rendered. This
document is prepared as a means of documenting and illustrating a breakdown of the total

amount that should be paid for the healthcare services that the hospital has conferred upon its
patients. The receiver of this document can be the patients themselves, their healthcare providers
or the insurance companies in which they have taken cover against such services (Tampa Bay
Associates, 2013).

The application and creation of the Charge Description Master is highly subjective to the scope
of a healthcare establishment’s operations. In smaller units, one is bound to find a single
document that details all the different services that a patient has received in the clinic. However
for larger establishments such as general hospitals this master document is prepared by the
different departments that have treated the patients. In the large hospitals’ case, the individual
master sheets are then condensed into one that summarizes the entire treatment costs and the
originals maintained for transparency and future reference.

Determination of Job Functions

To appropriately determine the Human resource requirements of both departments, I can conduct
a scaled down Human Resource Audit. The first item to consider and analyse will be the man-
power requirements of the individual departments as well as the current figure that has been set
aside to support them. The financial aspect will require input from the chief accountant while the
hospital’s HR department can give me pointers to the different requirements of each section. In
line with this, I will seek to find out if the critical positions are all occupied by competent
personnel. I will then inspect the current payroll in effect so as to find out if it is in accordance
with the job descriptions in force. An area of interest will be that of data entry especially in the
older facility where there seems to be a competence gap.

On the part of retention of employees, I will need to have a look at the welfare plan in effect as
well as the concerns that the workers have in this regard. I already know that they are uncertain
about their job security. I will also look at the way annual leaves are administered in the
departments of interest. Other employee benefits and bonuses will also be looked at analytically.
I will also make sure there is an effective system of employee appraisal in place. The issues that
need to be addressed will be dealt with in a consultative manner that takes into account the
interests of the hospital as well as the workers thus striking a reasonable compromise.

Potential Challenges that may arise

The challenge that I may face during the planning process is first of all the potential budgetary
constraint that is bound to arise given the fact that the hospital’s finance department has already
committed its finances into the costly process of acquitting the clinic. This can be addressed by
highlighting that this process is bound to bear great fruits in terms of savings and higher profits
as a result of increased efficiency in the running of the hospital. The plan should be looked at as
an investment rather than just another expense where money only goes out.

The second challenge that I may face is people’s resistance to change which is a natural thing
once someone has gotten accustomed to one way of doing things. This will make it hard to
accurately assess the needs that are currently present in both departments. To arrest this situation,
In light of this, I have to ensure the workers are well involved through a consultative process of
planning so as to limit the negative impact that the changes are bound to have on their morale.
This will also help to deal with the problem of technophobia which makes some people resistant
to the introduction of new technology.

In the scenario presented above, the main challenge that is affecting productivity is overstaffing
inn some areas and understaffing in others. The new clinic for instance has only one technical
worker who is able to handle the coding of patient date. In out hospital, this job has been given to
a front office worker who has stuck to the older method of manually inserting the values rather
than employing the digital technology which is available. Both of these instances are limiting
factors in as far as productivity is concerned.

Productivity Issues

Productivity issues can be determined by the outcome of work that is produced. In the hospital
for instance, the medical claims that have been prepared are often rejected owing to the errors
that are committed during their preparation. This means that whoever is charged with the
responsibility of their preparation is not conversant at all with what he is doing. This has been
discovered as a result the high number of rejected claims that my predecessor left behind.
Another way of investigating productivity concerns is by following issues heard over the
grapevine keenly since workers are bound to discuss the challenges that they are facing. This can
be addressed by holding an open forum whereby those who feel that their productivity is
hampered for one reason or another can raise the possible reasons for that case. At the same time,
departments that are not performing particularly will be put to task so that they can explain why
they are unable to deliver. If there is anything they need from the management side, such as
further training or otherwise it may be provided (Napier Healthcare, 2013).


Tampa Bay Associates (2013) CDM File Management Challenges and Solutions to Create User-
Driven Billing Solutions and Maximize Revenues