CASE 5-3 Developing a Coding Quality Plan

You have just been promoted to coding supervisor at a 300-physician clinic. The previous supervisor was terminated for incompetence. The coding section is a disaster. There are two full-time coders. One has one year of experience and is a recent graduate of the local college. Additionally, she has her Registered Health Information Technician certification. The other coder has four years of coding experience but no formal coding or HIM education. There is no coding quality program in place. There are no coding standards for either quality or productivity. There is a high denial rate (33 percent of your Medicare claims) due to coding problems. The accuracy level is currently at 72 percent. Your job is to resolve the coding section deficiencies. Since you have been promoted from within the facility, you are already aware of many of the problems. Your facility is in serious trouble with the Quality Improvement Organization (QIO), and you fear that the Office of Inspector General (OIG) will show up on your doorstep soon. Although not all of the financial difficulties the physician practice is having can be related to coding, many can, as the facility is not receiving proper reimbursement.

1. Identify what needs to be done to resolve the problems with the quality of coding.

2. Identify what needs to be done to reduce the denial rate.

3. Recommend a coding quality standard.

4. Recommend standards for the productivity of all types of coding (inpatient, emergency room, etc.).