HIM 422: Clinical Evaluations and Outcomes

Case Study 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 the 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. Review the attached case study for Developing a Coding Quality Plan. Based on your review, identify what needs to be done to resolve the problems with quality of coding?

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

3. Standards for coding quality exist within the profession. Research those standards. Recommend standards(s)/performance measure(s) for a coding QUALITY plan for your facility. (Provide resources used to determine measures- remember that you must provide a quantifiable measurement, such as a specific percentage of accuracy).

4. Standards for coding productivity exist within the profession. Research those standards. Recommend standard(s)/performance measure(s) for PRODUCTIVITY for each type of coding (inpatient, emergency room, outpatient). (Provide resources used to determine measures- remember that you must provide a quantifiable measurement, such as a specific number of charts coded during an 8-hour shift).