SUBDOMAIN 732.2 – Financial Resource Management and Healthcare Reimbursement

Competencies:
732.2.2: Clinical Coding and Coding Compliance – The graduate identifies and evaluates code sets associated with various levels of healthcare settings and articulates procedural and ethical guidelines, rules, and regulations for clinical coding within healthcare organizations.
732.2.7: Coding, Billing, and Revenue Cycle Processes – The graduate evaluates coding and billing functions and ascertains potential impacts to institutional revenue cycles for healthcare organizations.
732.2.8: Reimbursement Quality Issues – The graduate describes and compares models of quality reporting systems, explains how these models link quality to reimbursement, and evaluates the role of health information management for healthcare organizations.
732.2.11: Legal and Regulatory Environment – The graduate describes major components of the U.S. healthcare legal and regulatory environments and evaluates policies and procedures in healthcare organizations to ensure compliance with federal laws and regulations.

Introduction:

Health informatics professionals play an important role in the Health Informatics and Information Management (HIIM) team in the area of coding management and reimbursement processes. The Centers for Medicare and Medicaid (CMS) introduced quality reporting systems to link financial rewards to the provision of quality healthcare. The legal and regulatory systems that impact work processes in HIIM and throughout healthcare organizations are specific in their mandates; healthcare organizations and providers should adhere to the law to prevent legal consequences.

Health informatics professionals working closely with the revenue cycle must address quality at every level of the cycle. A thorough understanding of how the coding function impacts steps along the continuum of the cycle will help decrease the risk of errors. Awareness of the work of quality improvement organizations and attention to recovery audit initiatives help to build a culture of compliance.

In this task, you will describe various components of the coding and billing continuum and how errors may delay reimbursement or result in concerns of fraudulent practice. You will be required to discuss how several specific government directives have impacted healthcare organizations.

Requirements:

Write an essay in which you do the following:

A. Discuss the quality reporting systems sponsored by Centers for Medicare and Medicaid Services (CMS) by doing the following:
1. Discuss the goals of the Physician Quality Reporting System (PQRS).
a. Describe the advantages and disadvantages of the PQRS program.
2. Discuss the goals of the Value-Based Purchasing System (VBPS).
a. Describe the advantages and disadvantages of the VBPS program.
3. Describe the role of Health Informatics Information Management (HIIM) staff in participating in both PQRS and BVPS.

B. Explain the role of the quality improvement organizations contracted under the Centers for Medicare and Medicaid Services as it applies to the coding process.

C. Evaluate the importance of the following government initiatives:
1. Medicare and Medicaid Patient and Program Protection Act of 1987
2. Medicare Prescription Drug Improvement and Modernization Act of 2003: Recovery Demonstration Project

D. Summarize the following criminal statues as each relates to Medicare funding:
1. Stark II
a. Discuss the importance of Stark II to healthcare providers.
2. Anti-Kickback Statute
a. Discuss the importance of the Anti- Kickback Statute to healthcare providers.

E. Compare the importance of the Sherman Act, the Clayton Act, and the Federal Trade Commission Act to healthcare providers.

F. Compare the importance of anti-kickback statutes of both Stark II and the Medicare and Medicaid Program Protection Act of 1987 to healthcare providers.

G. Diagram the activities of each step of the revenue cycle in the order they occur.
1. Describe the work of HIIM staff members during each step of the revenue cycle in which they would be involved.

H. Describe the requirements of the HIPAA Transaction and Code Set standards.
1. Discuss the impact of the requirements on coders.

I. When you use sources, include all in-text citations and references in APA format.

Note: For definitions of terms commonly used in the rubric, see the Rubric Terms web link included in the Evaluation Procedures section.

Note: When using sources to support ideas and elements in an assessment, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the assessment.

Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section.