The HIM department’s role in the revenue cycle

The HIM department is responsible for ensuring medical record documentation is completed for every patient encounter (e.g., admission, emergency department, or clinic visit). Today, many of the controls that are in place to ensure an encounter is completely documented are automated or rely on technology. For example, an open encounter report is used in a clinic environment to identify those visits that do not have a clinic visit note.

Many organizations have been able to transition the analysis function from an employee manually reviewing the record for documentation deficiencies to rule-based deficiency identification and other rules-based workflows. For example, a rule is created to identify which records should have an operative report. If the operative report is missing, a deficiency is automatically assigned to a provider. Often, an account identified as having a deficiency is not routed to the coder until the report is completed, thus saving the coder from reviewing the record only to find a critical report is missing.

HIM’s use of such technology can improve timely and complete documentation, therefore decreasing costs overall.

Coding

Medical record documentation is reviewed for each patient encounter to identify appropriate diagnosis and procedure codes. The ICD-10-CM/PCS classification system and Current Procedural Terminology (CPT®) code set are the two tools used to translate diagnostic and procedural information in the record into codified clinical data. This codified data is transferred to the patient’s claim. It can also be transferred or stored in various data repositories. Coded data is used for:

• Justifying medical necessity and evaluating healthcare practices and trends
• Public health reporting
• Quality measurement conducted by external organizations
• Reimbursement (submitting a claim for billing and receiving payment)
• Research, accreditation, and credentialing

Physician query process

When reviewing a record, a coder may need to ask a question of a physician to determine the most appropriate code. A query process allows physicians to add or clarify documentation when the clinical information in the patient record is unclear or incomplete. Because unclear or incomplete documentation may directly affect coding quality, diagnosis-related group assignment, or the patient’s bill, the type and frequency of queries can be analyzed to target problematic conditions that require attention.

Coding accuracy audits

Coding accuracy is crucial to reimbursement, and coding guidelines are published by various official sources, including Medicare (program memorandums and local medical review policies), fiscal intermediaries, insurance carriers, and the American Hospital Association (in its Coding Clinic).

Adherence to ever-changing standards can be difficult to achieve without periodic review from both internal experts and external third parties. Depending on the encounter volume at a given facility and the results of prior audits, an organization may coordinate monthly, quarterly, or annual audits.

Requests for records/documentation (release of information)

The HIM department must ensure that requests from insurance carriers/payers for additional information to support claims payment are processed in a timely manner. Medicare has specific guidelines for the time frame in which additional development requests (ADR) are satisfied. During an ADR, a Medicare Administrative Contractor gathers information from a provider while the claim is still active. Regardless of who the payer is, delays in providing requested information can unnecessarily prolong the time before a facility receives payment for services rendered. Facilities also can identify proactively those payers or diagnosis/procedure groups that will require additional clinical information, such as an operative report, and send this information with the original claim to expedite payment.

Editor’s note: This article is an excerpt from “The Contemporary Guide to Health Information Management” by Chris Simons, MS, RHIA, Rose T. Dunn, MBA, RHIA, CPA, CHPS, FACHE, Lynette Kramer, MA, RHIA, and Laura Jacquin, RN, MBA.