Can someone help me with this scenario and question? Who's the coder No Ahima code needed

St. Anns Hospital is a 150-bed acute care facility in the Midwest. The facility's Case Mix index averages around 1.850. There are four inpatient coders and five outpatient coders on staff at St. Anns, and most have been with the organization for more than five years. All the coders at St. Anns hold American Health Information Management Association (AHIMA) credentials, many of them having both Registered Health Information Administrator and CCS or Registered Health Information Technician and CCS.

St. Anns has both inpatient and outpatient regular coding audits done on a quarterly basis. These audits are performed by an external organization that is a nationwide consulting firm. The audits address coding accuracy, appropriateness of documentation, optimal and appropriateness of reimbursement, and opportunities for education of coding staff and physicians. The results of the coding audits at St. Anns consistently demonstrate that the coders are performing at a 99% accuracy rate.

The coding staff at St. Anns has worked closely with the national consulting firm to ensure that their physician query process is appropriate, compliant, and thorough. The coders at St. Anns have developed an excellent rapport with the medical staff, and the physician query process operates in an efficient manner, with less than a 24-hour turnaround time. The coders are well-informed regarding how to present a physician query in a non-leading manner, maintaining the physicians role as the decision-maker.

Administration at St. Anns was contacted by Omar Shariff. Omar is a registered nurse who proposed to the administrators of St. Anns that he could implement a program that would improve reimbursement for the organization through improved provider documentation. Omar informed them that he had implemented the program at similar facilities and provided statistical information reflecting the change in reimbursement. Omar explained that he had thoroughly researched St. Anns practices and provided an estimate of the amount of increased reimbursement that they could anticipate utilizing his program. The administrators were impressed with his proposal, and they were in the process of reorganizing the case management department, so they created a new position for Omar Shariff.

Omars program was based on transferring all inpatient coding responsibilities from the coders in the Health Information Services department to the case management nursing staff on the patient care units. The rationale was that physician query could be performed concurrently during the hospitalization of the patients, so that late documentation after discharge would not indicate inadequate documentation reflective of poor care. Omar undertook the task of training the case management nursing staff how to code in two, four-hour sessions. He assured administration that his staff would fully understand all they needed to know about coding and diagnosis-related group assignment for optimal reimbursement.

Roxanne, the Director of Health Information Services, was informed by administration about the new concurrent program that would be implemented. She was told that this change was not negotiable and that her staff must adjust accordingly to their change in duties. Roxanne met with her inpatient coding staff to communicate the changes as they were outlined by administration. They would no longer be doing any actual coding; rather, their job descriptions changed to case abstracting and data entry. Roxanne shared the multiple concerns expressed by her coding staff. The concerns expressed by the coders included:

• Omar does not hold any formal coding credentials.
• The case management nurses have never had any other coding education.
• Coding is not something that can be learned and mastered in two, four-hour sessions.
• The existing coding staff members at St. Anns have AHIMA credentials that indicate they are at mastery level in their coding skills.
• Coding audits from a nationwide consulting firm indicate that the existing coding staff members have consistently been coding at 99% accuracy.
• Case management nurses have not had formal education regarding coding and reimbursement compliance, creating potential for non-compliant coding practices.
• What would happen to the existing coders jobs?

Roxanne recognized that she had expressed similar concerns to the administration when she was informed about the change and that this was not negotiable. She assured them that they would not be laid off as the result of the changes. The volume of outpatient encounters had increased so that some coders would be transferred to the outpatient coding area, and the rest would work on data entry.

Two of the inpatient coders resigned immediately, accepting positions at other local hospitals. The remaining coders continued to pursue compliance concerns with the changes being made and to research Omars history. They learned through their local network that Omar had implemented his program in four other hospitals in the state and been terminated shortly after each time. Eventually, they learned that he had been associated with a consulting firm that had been cited for fraudulent coding practices. The coders took these concerns to Theresa and then to the compliance officer and administration. They were repeatedly told that Omar had gone through a background check prior to his employment and that nothing significant had turned up.

Previous coders who had since become abs tractors for cases coded by case management nurses noted many significant errors in coding. The errors included the following:

• Sequencing of principal diagnosis other than what was indicated by the attending physician without approval
• Case management nurses writing diagnoses on the face sheet and coding without physician approval
• Physician query forms written blatantly leading to questions
• Incorrect code assignment
• Missing code for complications and co morbid conditions

The ab tractors took a sampling of the records with the errors to Theresa, the compliance officer, and the organization administrators. They were told that their jobs were no longer to code and that they should not be wasting time evaluating the work of the case managers. In response, the abs tractors developed low morale and a decreased sense of loyalty to St. Anns.

Discussion Questions

1. What additional flags should Theresa be suspicious of in this case?

2. Are there any issues presented in this case that are not in compliance with the AHIMA Code of Ethics?

3. Does Theresa have a legitimate case regarding the changes?

4. What internal and external forces impact the concerns of the inpatient coders in this case? Theresas concerns?

• Internal

• External

5. What ethical concerns are presented in this case?

6. What legal issues need to be considered regarding this case?