Paper Example: Current Process

Clinical coding constitutes one of the central roles in the field of health information management. In this case, clinical coding involves the application of health records as the source as source of information on a patient’s health. Usually, the specific coding conventions of the healthcare nomenclature vary due to the high risks of systematic errors (Antonio, 2017). The human judgment component of coding is another critical aspect that may trigger nomenclature variation, which causes a problem in the accuracy of coded data (Abdelhak et al., 2014). Furthermore, the complexity of resource grouping schemes and unclear information have been associated with nomenclature varies that triggers inaccurate coding (Chapman, 2018). The variation impacts the accuracy of medical coding, especially when health practitioners use incorrect diagnostic codes (Butler, 2018). A change in a single code could impact the accuracy of medical coding.

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In most cases, subjectivity in the coding process is a critical aspect that impacts the accuracy of data. Usually, there are numerous levels of subjectivity in the coding process, and this has been a critical aspect that impacts coded data to bring varying results (Chapman, 2018). In this case, the subjectivity level in coding is perceived as a major reason for the inconsistency (Antonio, 2017). Lack of a better understanding of coding is seen as a major aspect that impacts accuracy. Additionally, the lack of better training is another subjective aspect that impacts the coding process (Sayles, 2013). Usually, coders receive particular training on skills and theories that they are supposed to deploy during the coding process.

Organizational policies and resources are perceived as a roadmap that impacts day-to-day activities. In this case, policies and resources ensure coders in an organization comply with the law and regulations during the coding process (Butler, 2018). If a hospital does not have an active working plan, there are high chances that coders many encounter challenges during the coding process, which hinders the compliance approach (Sayles, 2013). Additionally, policies and resources impact the identification approaches that coders are supposed to deploy during the coding process (Chapman, 2018). Application of advanced resources, such as software, impacts an organization to documents all materials, thus promoting evaluation, which assists in eliminating errors during the coding process.

Human errors are perceived as a key factor that impacts the accuracy of medical coding. Usually, humans may incorporate bad and incomplete data, thus affecting the accuracy of the outcome (Butler, 2018). The approach creates an inconsistency coding process, which affects the trustworthiness of particular information (Abdelhak et al., 2014). Additionally, the lack of human skills and knowledge in collecting and coding is another critical aspect that triggers data inaccuracy (Antonio, 2017). Usually, failure to code properly negatively impacts the patients’ treatment care (Harrison & Association of University Programs in Health Administration, 2016). In this case, inaccurate human errors during the coding process trigger to improper patient care services (Chapman, 2018). For instance, missing a digit during the coding process could trigger a change in result, thus subjecting a patient to the wrong treatment program.

In the health care system, coding is identified as one of the core aspects of information management. As a result, health practitioners encounter various challenges in the coding process (Abdelhak et al., 2014). During the process, health practitioners are supposed to adhere to several rules and principles (Butler, 2018). All coders are required to apply accurate, complete, and consistent coding practices that yield quality information (Sayles, 2013). Additionally, coders are required to collect information in accordance with the application requirements (Chapman, 2018). Therefore, all the information is supposed to be supported by health record documentation according to health regulations.

Recommendations

Currently, technology application has become a crucial aspect that improves health performance. As such, the application of computer technology in various coding departments may assist in addressing issues related to data inconsistency (Sayles, 2013). For instance, the application computer-assisted coding application helps in optimizing coder productivity, which assists with the impending transition from ICD-9-CM to ICD-10-CM/PCS that impact the coding process (Butler, 2018). Additionally, the application of an automated coding process may assist the hospital in reducing massive errors that are causing by human factors (Abdelhak et al., 2014). Through the approach, the hospital will be in a position to improve data processing, thus improving the quality of health care.

As a result of changes in technology, there is a need to introduce a team of experts whose aim is to research the changing technology (Sayles, 2013). As such, the experts will be mandated to review the technology system that health care systems are using across the world (Antonio, 2017). Training will be another crucial aspect that will ensure the team shares the same skills and understanding of the coding process (Butler, 2018). Through the approach, it will be easier for the hospital to avoid some of the errors that may be experienced due to data process inconsistence.

As a way of promoting the coding process in the health center, there is a need for the organization to embrace a query policy. The policy will ensure all members of the team follow particular producers during the coding process (Butler, 2018). Through the approach, the team will be in a position to reduce data inaccuracy as they will effectively refer to a particular guiding system (Chapman, 2018). The approach will promote the specificity and completeness of the data, thus promoting patient diagnosis and treatment programs (Sayles, 2013). Additionally, the program should align with the hospital code of ethics to avoid other negative effects, which may affect the process.

Every day, there are new issues that are arising, and they need to be addressed for health care to maintain quality service delivery (Chapman, 2018). The application of the modern system is a crucial aspect that the hospital may use to address the current and prepare for future trends (Antonio, 2017). Through the approach, the hospital will develop accurate data processing, which will assist in attaining quality care initiatives (Butler, 2018). Additionally, the collected information will act as governance, which will impact the kind of systems to deploy to promote quality health practices (Antonio, 2017). Therefore, technology development is a crucial aspect that may assist health care in improving and attaining quality coding processes.

Quality process and accurate medical coding are crucial as they provide an accurate description of data, which assist in the diagnosis and treatment programs (Sayles, 2013). As such, it is easier for health practitioners to acquire accurate information, thus, promoting the evaluation processes, which assist in addressing issues in the hospital is facing (Antonio, 2017). Failure to code correctly may affect a patient’s treatment programs (Chapman, 2018). Additionally, inaccurate coding of the specifics during the diagnosis may result in improper patient care, thus affecting the quality of services the hospital provides.

References

Abdelhak, M., Grostick, S., & Hanken, M. A. (2014). Health information-e-book: Management of a strategic resource. Elsevier Health Sciences.

Antonio, S. (2017). Study show improper EHR medical coding causes inaccurate medical bills and lost revenue; EHR shortcuts to blame. PR Web Newswire.

Butler, M. (2018). Eight prediction for’ 18: Experts prognosticate the top him topics for the year ahead and advice on how to prepare.

Chapman, S. (2018). Best practices in coding audits.

Harrison, J. P., & Association of University Programs in Health Administration. (2016). Essentials of strategic planning in healthcare (Vol. 1). Chicago, IL: Health Administration Press.

Sayles, N. B. (2013). Health information management technology: An applied approach. L. L. Gordon (Ed.). American Health Information Management Association.