Assignment 1: Healthcare Compliance In Nursing Care

Azemobho Imaku

Western Governors University

Healthcare Compliance

December 15th 2015

An inpatient coder is a professional, skilled at performing coding and abstracting of inpatient accounts using ICD-9-CM (International Classification of Diseases Ninth Revision, Clinical Modification) and CPT (Current Procedural Terminology) coding systems. An inpatient coder is also expected to be knowledgeable in medical terminology, disease processes and pharmacology. Some of the key responsibilities of the position include assigning codes for diagnoses, treatments and procedures, reviewing provider documentation to determine principal diagnosis, ensuring accurate coding, identifying non-payment conditions and ensuring medical record coding meets regulatory

(2013), are implemented by hospitals to assure the health record accurately reflects the actual condition of the patient. AHIMA provides guidance for clinical improvement programs with goals which include identifying and clarifying missing, conflicting or nonspecific physician documentation related to diagnoses and procedures; supporting accurate diagnostic and procedural coding, DRG assignment, severity of illness, and expected risk of mortality which leads to appropriate reimbursement; promote health record completion during the patient’s course of care; improve communication between physicians and other members of the healthcare team; improve documentation to reflect quality and outcome scores and improve coders’ clinical knowledge. Developing a CDI program as a coding manager will include hiring credentialed and competent individuals with the right education and experience, providing training and in-services for staff and related departments that use clinical documentation on how specific and complete clinical documentation needs to be captured, making sure staff is knowledgeable in State and Federal laws and regulations that govern their positions, adheres to ethical standards set by credentialing and regulatory organizations and making sure staff is aware and exposed to changes and improvements in the industry through continued

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LaTour, K., Maki, S., & Oachs, P. (Eds.). (2013). Health information management: Concepts, principles, and practice (4th ed.). Chicago, IL: AHIMA. ISBN-13: 9781584263593

Schnering, P. (2014). Professional review guide for the RHIA and RHIT examinations. Cengage. ISBN 9781305325111

Sturgeon, J. (2010) Tips for Setting Productivity Standards For The Record Vol. 22 No. 14 P.