1. Healthcare Compliance and Coding Management Effectiveness Scenario
You have recently taken a position as supervisor for a health information management
(HIM) department at a rural hospital. Your staff consists of three coders who all perform
inpatient coding services. One of these coders also performs coding services for a physician
who treats patients in a small outpatient center attached to the hospital.
You also manage a front office employee whose job duties are answering phones, assisting
walk-ins with release of information and other requests, filing, and retrieving health records
from hospital departments. The hospital implemented an electronic health record about six
months ago, but there are still many providers using paper documentation during this
transition period.
The chief financial officer (CFO) informed you yesterday that the hospital is purchasing an
existing outpatient clinic located in a small town about 50 miles from the hospital. Currently,
this clinic has one provider who sees 20–30 patients daily. There is a local lumberyard and
small farm equipment manufacturing plant in town, both of which contract with the clinic for
medical services for injured workers.
The CFO anticipates the clinic may be more convenient for some patients, and there may be
a decrease in patients seen at the hospital’s outpatient center. The CFO’s preliminary
projections for patient numbers indicate that you will need to eliminate one of your coding
positions within the next six months. The CFO informed you that the clinic has several longterm employees comprised of nursing staff and a front office staff member who performs
coding and billing functions while also attending a local community college to become a
registered health information technician (RHIT).
Today when you came into work, you overheard your staff expressing concern to each other
about the rumor they heard about one of them being fired. They quickly quieted when you
arrived and went to their own desks to begin working. Later, one of them came to you as
spokesperson for the group and explained their concerns, asking you for the truth. You
explained that you needed to gather more information from your superiors and promised a
staff meeting before the end of the week to discuss the issue. The spokesperson left your
office looking stressed.
You worked most of the morning on several rejected Medicare claims left from the previous
HIM director. You had hoped to begin reviewing the policy manual to determine HIM
department quality standards and department processes because the nature of some of
these claims troubled you. When you asked about some of these long-standing claims, the
CFO just shrugged and told you to handle it.
Your thoughts were interrupted by a phone call from the hospital charge master coordinator
who was calling for information about the position at the clinic. The coordinator lives about
10 minutes from the clinic and would enjoy eliminating the long drive to the hospital each
day. As a 15-year employee with the hospital, the coordinator feels the job offer would be
well deserved. You politely express thanks for the call and explain that any interest should
be directed to the human resource office. After the call, you sit at your desk wondering why
you did not just keep your position as coding coordinator back in your hometown. Maybe
this cross-country move was not such a good idea after all.

2. After reading the attached “Healthcare Compliance and Coding Management Effectiveness Scenario,” that gives a
description of several problems that I might face as a newly hired health information management (HIM) department
manager. First of all I will come up with a way of determining the types of coding functions that are necessary to make the
HIM department effective. I will also evaluate staff qualifications, criterias for hiring and downsizing personnel. Through all
this, I will attempt considering the HIM workflow along with productivity and departmental quality concerns, hence improving
decision making process.
To systematically come up with solutions to the challenges presented in the scenario, I would organize a number of
meetings with the concerned people in their respective departments. This will help in pinpointing some of the challenges and
creating a roadmap on how to tackle some of the problems in these departments.
The various job functions of the current staff definitely vary .Starting from the top, the chief financial officer who is charged
with coordinating all the activities of the now merged hospital. The health information manager has to keep all the details and
information regarding patients admitted in the hospital. Then we have the outpatient clinic billing department which basically
performs the coding and billing functions for the patients treated at the outreach site. The oncologist sees patients on a
regular basis and the nurses work around the hospital, others are attached to the oncologist’s office, where they administer
chemotherapy.
According to Safian, S.(2009),some of the concepts and processes behind code look-up soft ware-an automatically updated
and set up CPT codes is to help in ensuring easy and CPT Code Lookup functionalities. The encoder software is for
converting information into the required format for storage in the hospital systems. Charge description master table is for is a
comprehensive listing that comprise of all items that could be billed any patient, to the payer or to healthcare provider.
To determine job functions that are needed at the hospital and the new clinic a task force has to be put in place immediately
to come up with some of the necessary functions. I would structure a plan for recruiting, hiring, and retaining staff in these
departments on purely merit and productivity basis. Some of the other people who may be helpful to me in the planning
would include the human resource manager and some of the top officials in his department. All the challenges that may arise
during the planning process will be handled immediately to avoid them impeding progress.
When it comes to matters to do with productivity and quality standards as they appear to be common if the presented
scenario is anything to go by, first I would install in place a task force to immediately collect all the data and information that
is required to help bring change. The concerns that would emerge will have to be ranked in order of preference and seek
advice and assistance from relevant authorities.
Like it is said, the health information management (HIM) compliance program, including the coding function, is very critical to
a healthcare organization. Third-party-payer reimbursement is dependent upon accurate coding. The HIM compliance
program should be in alignment with the organizational compliance principles and standards required by regulatory
agencies. First of all in this scenario, an outline of a HIM compliance plan that emphasizes the coding function has to be in
place. Some of the very important components of the plan will have to include values of the hospital and many more like
responsibilities of each worker. Explain the responsibilities that each staff has to carry out will be well stated to ensure that
there is accountability. The HIM has to be linked to most of the external agencies that are charged with monitoring
compliance. These agencies will only disseminate information formally upon consulting.
For the sake of outlining guidelines for implementing this plan, some vital elements have to be included in the policies within
the plan. For instance accuracy has to be strictly adhered to and this has to be ensured by doing double coding which will be
duplicated elsewhere. For the sake of transparency, noncompliance will have to be reported and any breach of this policy
will be punished severely. Incase of any form of noncompliance being noticed by an external audit, the individual responsible
will lose his or her job. This plan has to be evaluated by a panel of in depended auditors and evaluators.
A coding compliance training program has to have some vital elements that must be looked into .For instance a way has to
be reached of identifying the needs. And for all this to be possible an area that has to be keenly looked into is how the
training program should be evaluated. This will have to be very thorough so as to avoid problems such as
unprofessionalism.
Introduction
Healthcare coding personnel use information provided in clinical notes from healthcare providers in
order to convert this information into a code. Coders will review the information provided in health
records to identify diagnoses and procedures, in order to “translate” this information into an
appropriate code. Healthcare coders must have training in medical terminology, diseases, injuries and
healthcare procedures in order to ensure accurate translation of medical notes into these codes (Grain
and Hovenga. 2011). The use of coding schemes (such as ICD-9) allows for consistency in
documentation between different healthcare providers. This allows for more efficient communication

3. of a patient’s condition between different platforms within the healthcare system. Information
gathered from coding systems is used for several purposes, such as determining reimbursement for
services, statistical research and cost-benefit analyses, just to name a few possibilities.
Part A1: Addressing the Challenges
The health information management (HIM) supervisor in this scenario has been put in charge of
assisting in the transition brought upon by the acquisition of a new clinic by the parent hospital. She
must determine the most effective way to provide appropriate staffing for both sites, while possibly
having to eliminate one of the coding positions to accommodate the change.
The HIM supervisor has been at the facility for a short time, so she may not be fully aware of what job
assignments each staff member currently has. Getting a full understanding of how work is divided
among her staff will help her make better decisions regarding staff downsizing, if needed.
The HIM supervisor is responsible for overseeing four employees as described in the scenario. The
front office employee is cross trained to perform both clerical and HIM-related duties, such as
managing requests for release of health information, filing and requesting health records from...