Critical Case for Billing and Coding

Root Cause of the Problem 

Improper coding at the community hospital has led to the lowering of the level of the hospital's chargemaster, which is at the heart of the healthcare revenue cycle (Reyes et al., 2017). Mostly, the problem has been manifesting itself in the outpatient visits, which have led the hospital to operating at a loss due to the thin profit margins. 

Ways to Mitigate its Impact 

Billing processes can be automated to mitigate the happening of the coding errors contributing to fluctuation in revenue. The employees will be taught how to critically analyze the correct level of care while selecting a procedure code (Haviari et al., 2018). The comparison of the usage of the hospital’s finances will come up with the possibilities of having a clerical error leading to 15% reduction in the revenue. With the careful consideration and the changes instituted to the coding process at the community hospital, the institution will be in a position to pinpoint the billing and coding errors, as they appear and deal with them (Haviari et al., 2018). 

Solutions to the Problem 

The Chief Financial Officer (CFO) has engaged a team of the other specialists at the hospital, including the former CFO to identify the possible solutions to improper coding that can be implemented within a short time to revert the poor performance of the institution based on its revenue. The first solution is having the controller run a volume report ( Brusselaers, Mattsson & Lagergren, 2014) . The report is meant to compare the annual performance of the hospitals concerning finance. 

Since the volume report does not indicate any shortcomings that may be reducing revenue at the hospital, the other option is to concentrate on coding ( Holden et al., 2013) . Coding problems at the hospital could be that the charges are not being generated, computer hitches, or problems in claims ( Andrews, 2015) . The employees of the community hospital involved in the billing and coding activities will be regularly educated on the review of publications and staying updated with the continually changing medical and billing processes in the healthcare sector. 

In the bigger picture, paying attention to the little details in the coding process will raise the revenue of the hospital in the end by reducing the amount of money that the hospital loses in the improper coding. 

References 

Andrews, R. M. (2015). Statewide Hospital Discharge Data: Collection, Use, Limitations, and 

Improvements. Health services research , 50 , 1273-1299. 

Brusselaers, N., Mattsson, F., & Lagergren, J. (2014). Hospital and Surgeon Volume in Relation 

To Long-term Survival after Oesophagectomy: Systematic Review and Meta-analysis. Gut , 63 (9), 1393-1400. 

Haviari, S., Chollet, F., Polazzi, S., Payet, C., Beauveil, A., Colin, C., & Duclos, A. (2018). 

Effect of Data Validation Audit on Hospital Mortality Ranking and Pay for Performance. BMJ Qual Saf , bmjqs-2018. 

Holden, R. J., Rivera-Rodriguez, A. J., Faye, H., Scanlon, M. C., & Karsh, B. T. (2013). 

Automation and Adaptation: Nurses’ Problem-solving Behavior Following the Implementation of Bar-coded Medication Administration Technology. Cognition, Technology & Work , 15 (3), 283-296. 

Reyes, C., Greenbaum, A., Porto, C., & Russell, J. C. (2017). Implementation of a Clinical 

Documentation Improvement Curriculum Improves Quality Metrics and Hospital Charges in an Academic Surgery Department. Journal of the American College of Surgeons , 224 (3), 301-309.