Healthcare Compliance Scenario (First Draft)

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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 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,

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