March 2, 2009

A Manager’s Role in Encouraging Compliance
By Christina Benjamin, MA, RHIA, CCS, CCS-P
For The Record
Vol. 21 No. 5 P. 8

“These are the times that try men’s souls…”

— Thomas Paine

Over the past several weeks, I have found myself responding to numerous requests for advice from coding and reimbursement professionals who believed they were in situations where management was instructing them to adopt questionable coding and billing practices. Having been a victim of this same situation myself, I felt inspired to discuss this topic in depth and to share some lessons I have learned both from my own experience and also from my experience advising others.

We all know the code of ethics that medical coders make a part of their professional lives and follow each day. For example, “Coding professionals, as members of the healthcare team, should assist and educate physicians and other clinicians by advocating proper documentation practices, further specificity, and resequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity, and the occurrence of events.” (The full list can be found at www.ahima.org/infocenter/guidelines/standards.asp.) How many of us have found ourselves poring over documentation provided by a physician and becoming frustrated at the lack of documentation?

While documentation improvement programs are wonderful, they are of no use without the power to implement the steps in a department. Many coders can suggest methods to boost documentation to their supervisor or manager, but the end results of that information lie with the manager. Currently, there seems to be a lack of information available on how to properly manage a coding department in an office or hospital setting. That’s unfortunate because there are plenty of issues that need to be addressed, and coding managers have a responsibility to create a work environment where staff members can thrive.

With plenty on their plate, coding or office managers can often be torn due to pressure from upper management, lack of rapport with physicians (especially in a hospital or facility setting), and staff needs. As a result, a manager can easily fall into the habit of bending the rules to meet these pressures and demands. What often happens is that a vicious cycle develops and the organization or office begins to accumulate a huge compliance risk. The coders may recognize the problems and raise concerns or questions.

The responsibility lies on the manager to make employees feel comfortable sharing their thoughts about potentially serious issues, assuring them that they will be heard and a resolution will be sought as soon as possible. Managers must understand that their staff members need to know the work they’re performing is ethical and compliant. Staff can become extremely stressed and unhappy when they feel forced to comply with instructions that are unethical. 

Because a manager has numerous responsibilities, it can be easy to put a coder’s concerns on the back burner while other seemingly more pressing issues are addressed. This most often occurs in a remote or virtual environment where the coders are miles away from the office, resulting in a sort of “out-of-sight, out-of-mind” effect. Limited contact can make it more difficult for managers to convince staff that their voices will be heard and conflicts will be resolved swiftly and efficiently.

To give employees another option besides reporting to their manager, many healthcare organizations implement compliance hotlines. Plus, there is always the whistleblower option. However, coding managers should always seek to address concerns on a more personal level so that staff do not feel driven to these means.

Also, it should not take a year or two to solve a compliance issue; the problem should be resolved as soon as possible.

Here are a few tips on how managers can encourage coders to bring compliance issues to their attention. Remember, the goal is to create an environment conducive to open communication, no matter the subject.

1. Provide constant and interactive education for staff. For example, review key updates and principles that can be gleaned from official sources such as Coding Clinic and CPT Assistant. In many offices, coders are only required to read these publications while in the remote world, and reading is often not even a requirement. Coding managers should provide interactive means for educating coders, either via an e-mail or newsletter format or department meetings and conference calls.

Other key news regarding regulatory updates, including Medicare guidelines, official coding guidelines, and facility-specific guidelines, should also be relayed to staff on a consistent basis. These guidelines should be reviewed periodically, and any changes should be highlighted. Key problem areas from past audits or impromptu audits should also be reviewed.

2. Post the AHIMA Code of Ethics for coding professionals in a prominent place and be sure to refer to them in staff meetings.

3. In meetings, constantly invite staff to share any concerns or issues regarding compliance or other areas.

4. Store all up-to-date guidelines in an easily accessible notebook or an electronic file, especially those in key gray areas such as nonoperative procedure reporting and chronic conditions. Facility-specific guidelines should include issues such as payer-specific guidelines, unresolved coding issues, coverage issues, and any local or state reporting guidelines. Clear and consistent expectations must be communicated on a regular basis.

In a virtual or remote setting where the organization codes for various clients, managers also must be concerned with employee retention rates and workload variances. For example, suppose a particular client has refused to provide the proper documentation necessary for timely and accurate coding. Management should carefully evaluate the following questions:

• Can we work with this client to quickly solve this compliance issue?

• Will this client be responsive to our efforts?

• If this client is not responsive, do we need to consider terminating the contract?

• Can we consider refusing to code any accounts for which proper documentation is not allowed?

• If the contract is terminated, do we have sufficient work to keep the coders who were working on this account busy?

• How do we handle internal auditing when the facility has instructed the coder to code a certain way?

These are not easy questions to answer, but it’s necessary to formulate the best response possible to ensure the healthcare organization is doing everything possible to remain compliant.

— Christina Benjamin, MA, RHIA, CCS, CCS-P, is an independent coding and education consultant in East Dublin, Ga. She works with physician champions, auditors, managers, and coders and is involved with creating or overseeing the development of tools and resources specific to the new Medicare severity diagnosis-related groups.