by Stacy Swartz, RHIA, CCS, CPC
Establishing a Quality/Compliance Program Coding quality has always been critical. Coders are held to high standards and an expectation to achieve a greater than 95% accuracy rate is common. Coder accuracy impacts reimbursement, benchmarking, clinical and financial decision making, and publicly reported data on quality of care. A comprehensive quality and compliance program is critical.
Consider the following elements when designing your quality and compliance program:
Standards and Procedures
Develop standards and operating procedures to support your quality program. Define the scope, accuracy requirements, methodology and schedule. Determine the process for coder review and audit; define thresholds accordingly. Reward excellence. But also don’t be afraid to address less than optimal performance, that if necessary may result in 100% review, a work improvement plan or learning path, reassignment, or even termination.
Who is responsible for your organizational quality? Most commonly, this role is held by a compliance officer or the director of quality assurance. Is this you? Determine what works best for your organization but remember to seek qualified, credentialed individuals that are independent of your operational teams.
Education and Training
Mandatory training and education is the backbone of a quality program. Training should be engaging and geared to the adult learner. It should build on their current base of knowledge and challenge them to strive higher. The training should be clearly focused on what they need to know to do the work that needs to be done. Incorporate specific and general issues into your training material and deliver it in an objective manner.
Monitoring and Auditing
Perform continuous internal quality reviews, preferably monthly, but no less often than quarterly. The standard sample size is 10% of case volume, but auditing for specific topics known to be an issue may provide greater value in coding improvement. Validate the reliability of your internal reviews by conducting an external review on an annual basis. Do not forget to audit your quality assurance team too! They provide feedback directly to your coders. Inaccurate coding directives or failure to implement yearly updates could quickly sink your ship!
Adhere to the policies you created for your quality program. It does not matter how robust your program is if you do not enforce the process. Set the standards and enforce them! Consistency is key.
This article is an excerpt from the Libman Education white paper “Does your Coding Team Meet Your Standard of Quality? Four Principles to Help your Coding Team Succeed.” Request your free download here.
eLearning Library Subscription
Unlimited access to over 60 courses, assessments, and training curriculums designed to enhance job-specific, self-paced learning for one full year.
Special pricing available for Groups. Train your entire team! Learn more here.
About the Author: Stacy Swartz, RHIA, CCS, CPC
Stacy Swartz has 25 years of experience in Health Information Management, having worked all facets of the profession from coding to billing to Vice President of Operations. With expertise in both professional and facility service lines, she has served as an educator and consultant to over 2,000 coders and upwards of 400 physicians. Ms. Swartz’s coding experience includes both inpatient and outpatient services, having worked with several of the largest Health Systems and Hospitals in the industry.