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Coding compliance and ethics: Make it work and be effective

Gloryanne Bryant ( is Executive Director and Consultant at HIM Coding in Grass Valley, CA. and is also an AHIMA-approved ICD-10-CM/PCS trainer.

Financial reimbursement in healthcare entails lots of pressure, which can lead to or result in a false claim or false claim activities. “A false claim can take many forms, the most common being a claim for goods or services not provided or provided in violation of contract terms, specification, statute or regulation.”[1] Understandingly, eliminating healthcare fraud, waste, and abuse remains a top priority for the federal government. Simply review the Office of Inspector General (OIG) annual and semi-annual reports, and you’ll see that we are talking about billions of dollars that are labeled “fraud, waste and/or abuse.” Don’t forget that a false claim can occur in many sectors and settings of healthcare. Certainly the clinical codes that drive reimbursement put added importance and attention on having a coding compliance and ethics program in place.

For those who work in clinical coding and/or are coding professionals, their work is often under a microscope, and for good reason — numerous risk areas surround documentation and coding. Volumes of rules and guidelines must be followed, which often are open to interpretation. The April 2017 report from Crowe Horwath titled, “20 of the Top Risk Areas in Healthcare,”[2] included these risk areas related to clinical coding:

  • Clinical Documentation Improvement (CDI)

  • Billing and collections

  • Inpatient coding

  • Charge capture

  • Physician practice coding and billing

When we know the risk areas and/or potential risks, we can start with the seven key compliance elements[3] and see if they are in place before diving into the coding compliance program/plan:

  • Standards of Conduct

  • Compliance Officer and Board/Committee

  • Education

  • Auditing and Monitoring

  • Reporting and Investigations

  • Enforcement and Discipline

  • Response and Prevention

These elements should be a foundational guide for any and every healthcare organization, company/system, practice, hospital, clinic, etc. The seven elements can then be built into a coding compliance program and/or plan to outline the effort and work to be carried out.

Last year, the healthcare community and industry received a wonderful resource guide, “Measuring Compliance Program Effectiveness; A Resource Guide” from the HCCA and OIG.[4]

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