EHR Adoption in LTC and the HIM Value. Appendix D: The HIM Professional as a Compliance Officer in LTC

Hospitals developed compliance programs in response to a 1991 federal Sentencing Commission policy mandating penalties for organizations convicted of federal crimes. These federal crimes include fraud and abuse of the Medicare and Medicaid programs. If an organization's compliance program includes a risk analysis process, a compliance officer and compliance committee, a process for auditing and monitoring, evaluation of audits, and staff training and disciplinary actions for staff, the program would evidence the corporation's intention to do the right thing by self-monitoring. If the corporation encounters trouble with the federal government, the compliance program would be weighed in determining penalties.

In 1998 the Office of the Inspector General of the Department of Health and Human Services published voluntary "Compliance Program Guidance for Hospitals" in response to organizations asking for help developing a program that would follow the Sentencing Guidelines. A voluntary program for nursing facilities followed in 2000. A compliance officer uses this guidance as a benchmark to identify if the facility has an effective compliance program.

Health information professionals have an advantage over other personnel entering the compliance field because of their training. HIM staff has valued experience in coding and working with the clinical record. The ability to locate information and understand clinical documentation is necessary to determine risks the organization faces. For healthcare compliance a risk analysis identifies what chart audits to perform to determine if the facility has adequate processes in place to comply with government regulations or its own policies and procedures. A compliance officer without HIM training must delegate these important audits to another party, thereby relying on that person's ability to understand and abstract relevant data and interpretation of the results.

Coding and billing are high risk areas that facilities and government auditors track. The Centers for Medicare and Medicaid Services require facilities to use current code books and follow "Official Coding Guidelines" when placing diagnoses on the billing form. Codes support medical necessity but do not determine the reimbursement rate in long-term care. The "coding" used by nurses to complete the resident Minimum Data Set assessment form determines the facility reimbursement rate by assigning Resource Utilization Groups, or RUGS. The long-term care diagnoses used in the MDS resident assessment should support codes placed on the facility billing statement. Coding background is essential to ensure that the chart documentation supports the diagnosis codes assigned on the MDS and billing statements.

Compliance officers must understand the different regulations governing MDS reporting versus clinical coding. MDS reporting has a "look back" period that includes services performed in the hospital. ICD-9-CM coding defines services performed upon admission to a long-term care facility. Assigning acute care codes for conditions resolved in the hospital on the billing statement may flag a government auditor to investigate potential "upcoding" and medical necessity of services.

Leadership is the ability to influence others to attain a goal. Leadership is the foundation of a compliance program. Administrative support is necessary for an effective compliance program, but the ability to communicate complex processes and win the cooperation of different professional levels within the organization cannot be overstated. Effective communication relies on a knowledge base in health information fundamentals to promote understanding of auditing principals with your audience.

A compliance program depends upon a knowledgeable leader to inspire ethical conduct and application of compliance principals in all members of the workforce. The HIM profession is familiar with this code of conduct and understands the importance of maintaining a work ethic that promotes dong the right thing. One of the most difficult duties of a compliance officer is following an unpopular ethical principal and changing the corporate culture.

Information on training and certification for the healthcare compliance officer position is available through national compliance associations. Monthly magazine articles, webinars, and seminars on different topics provide understanding of various compliance principals. This training provides a background that allows a candidate to sit for the credentialing examination. Most employment opportunities for compliance officers ask for a compliance credential with the additional skills of the RHIA preferred.

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Article citation:
AHIMA. "EHR Adoption in LTC and the HIM Value. Appendix D: The HIM Professional as a Compliance Officer in LTC." Journal of AHIMA 82, no.1 (January 2011): expanded online version.