Explain the role of a quality improvement organization contracting under the Centers for Medicare and Medicaid Services as it applies to the coding process.


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 helps 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.


A. Evaluate the importance of the following government initiatives as they pertain to the coding function:

1. Medicare and Medicaid Patient and Program Protection Act of 1987

2. Operation Restore Trust

3. Medicare Integrity Program

4. Medicare Prescription Drug Improvement and Modernization Act of 2003: Recovery Demonstration Project

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

C. Diagram the activities of each step of the revenue cycle in the order in which they occur.

1. Describe the work of HIM staff members during each step of the revenue cycle in which they would be involved.

D. Illustrate how you would address the following automated billing report errors:

1. The date of service on one portion of the bill for a same-day surgery was not in agreement with the date on other portions of the bill

2. The diagnosis and procedural codes were inaccurate

3. A procedure was billed to the wrong patient

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

Note: When bulleted points are present in the task prompt, the level of detail or support called for in the rubric refers to those bulleted points.

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 a paper or project, 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 paper or project.

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 General Instructions section.

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