Coding Leadership Resource Guide: Promoting a Culture of Compliance

MRA Templates (landscape)-Jan-16-2023-08-09-25-1912-PM

Clinical or Medical Coding takes place across all settings in healthcare. Here in the United States, our healthcare system (industry) is extremely dependent upon the coding process and the selected codes for compliant billing and reimbursement. Those individuals in a management role must exude leadership, partnered with compliance in order to achieve the level of integrity and positive outcomes desired. Understanding how best to marry leadership with compliance takes skill, dedication and other attributes to achieve success.

Coding professionals don’t simply select a clinical code (ICD-10-CM/PCS or CPT) from a list based on what is or is not documented in the medical record. Coding professionals have to have a strong knowledge of medical terminology, anatomy/physiology, disease process, and pharmacology. In addition, the coding professional must have a thorough and complete understanding of the coding classification system and its structure. There are Official Guidelines for Coding and Reporting and rules that must be followed and there is a volume of instructional notations within the coding classification system itself that also must be followed. Not to be forgotten is the AHA Coding Clinic guidance which is published quarterly. So, in all, it takes experience, skill, expertise and integrity to be a coding professional and specifically a Coding Leader in order to obtain and maintain compliance.

The Office of Inspector General (OIG) has provided several compliance program guidance’s, in particular, the hospital compliance guidance of February 1998 and the supplemental compliance guidance hospital in June 2004.

The OIG’s Seven Key Elements of a Compliance Program Include:

  1. Implementing written policies, procedures and standards of conduct.
  2. Designating a compliance officer and compliance committee.
  3. Conducting effective training and education.
  4. Developing lines of communication.
  5. Conducting internal monitoring and auditing.
  6. Enforcing standards of conduct through well publicized disciplinary guidelines.
  7. Responding promptly to detected offenses and undertake corrective action.

Review and utilize this program guidance along with the OIG Work Plan, the OIG audit reports and the OIG annual report to assist in driving compliance across the workplace and workforce. Each of the elements can and should be included in your own department or organizational Coding Compliance Program/Plan. HIM Coding leadership with regard to compliance cannot be understated.

A Coding Leader should stay abreast of information and guidance from the Centers for Medicare and Medicaid Services (CMS). CMS has developed and posted several great resources regarding clinical documentation on their compliance. With clinical coding being based upon the health record documentation these tools, etc., can help and serve as an asset.

Health Information Management or HIM often oversees the coding staff and coding processes. This includes auditing, monitoring, education and compliance.

Communication, collaboration, and cooperation are key to achieving compliance in one’s daily work for any staff member and in particular the “leader”, but certainly an imperative in the coding world. Let’s look at the definitions below which all include a “process”:

Communication is the process of sending and receiving messages through verbal or nonverbal means, including speech, or oral communication; writing and graphical representations (such as infographics, maps, and charts); and signs, signals, and behavior.

Collaboration is the process of two or more people or organizations working together to complete a task or achieve a goal.

Cooperation is the process of working together for mutual benefit.

I also believe strongly that having transparency and ethics as a leader is essential or there could be a collapse of the integrity and quality of the clinical coding and negative compliance ramifications can result.

A great resource for coding professionals is the AHIMA “Standards of Ethical Coding” to help guide our profession and this serves as an excellent tool and resource. The Standards of Ethical Coding include a total of eleven (11) essential principles. A good leader will utilize this resource regularly and apply it in their daily coding management activities. Leadership must promote a culture of coding compliance through both their actions and words.

I’ll close with one of my favorite quotes from Martin Luther King, Jr. “the time is always right to do what is right.” I ask you to think about this quote and how it impacts you as a leader and specifically as a leader in clinical coding and within coding compliance.


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AHIMA Approved

This program has been approved for continuing education unit(s) (CEUs) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting of Approved CEUs from AHIMA does not constitute endorsement of the program content or its program provider.