The Future of HIM Audits

ByAGSHealth

“Health information management (HIM) is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. It is a combination of business, science, and information technology.”AmericanHealthInformationManagementAssociation(AHIMA)

Healthinformationmanagement(HIM)playsavitalroleinmappinga successfulfutureforhealthcare.Oncelimitedtomedicalcoding,dataanalysis, andotheradministrativetasks,HIMhasexpandedtocovermedical technologies,informationdigitization,andtheproliferationofwearables.All ofthesehavecreatednewavenuesforobtainingpatient-generateddataand areredefininghowwethinkofHIM.

Asaresult,theresponsibilitiesofHIMprofessionalshaveexpandedtoinclude informationsecurity(tomaintaintheconfidentialityofmedicalrecords),as wellasconductingresearchanddrivinginnovation.

HIMprofessionalssupportthecontinuousimprovementofmedicalcodingby curatingdataforpatientrecords.Documentationauditshelptoidentifygaps inpatientrecords,whichthenallowsHIMprofessionalstocuratedatafrom othersystemstofillthegaps.

Errorsinmedicalcodingcanleadto:

• FalsepositivesinPatientSafetyIndicator(PSI)rates

• Blurredlinesbetweenactiveandresolvedhealthconditions

• Reducereimbursements

• Lostrevenueduetoclaimdenials

• Noncompliancewithregulatorystandards

Allofthesecanbeavoidedwithdocumentationaudits,whichidentifyand helptofilldatagaps–reducingclaimdenials.

ICD-11 Brings 41,000 New Codes Contributing to Complexity

Medicalprovidersandhospitalexecutivesunderstandthatfull reimbursementrequiresaccuracy.Documentationauditsareacrucialstepin providers’reimbursements.ThetransitiontoICD-11(International ClassificationofDisease,11thversion)willaddasignificantnumberof diagnoses,increasingfrom14,000inICD-10tomorethan55,000unique codes.Codesthatmedicalcoderswillneedtobeawareoftopreventerrors andmissingdocumentation.

ThetransitiontoICD-11willrequireHIMprofessionalstomonitorICD-11 planning.Teamswillneedaclearunderstandingofthenewcodeset.Nowis thetimetobeginpromotingICD-11education,training,andworkforce development.Thiswillensureyourteamiswellpreparedforthetransition.If teamsaren’tprepareditcouldleadtoincreaseddenialsandadecreasein reimbursements.

Byestablishingclinicaldocumentationimprovement(CDI)teams,HIM departmentscanensureclinicaldocumentationcaptureisprioritized. Comprehensiveinpatientandoutpatientdocumentationauditsallowfor:

• Moreaccuratecoding

• Programreviews

• Queryintegrity

Thishelpsmedicalcodersimprovepatientrecordkeeping,facilitatetimely claimspayments,anddrivebetterpatientcare.

Securing the Investment for Medical Record Optimization

AccordingtoaTechnologyInnovationinHealthcareSurveybyHIMSSMedia, 52%ofrespondentsstatedtechnologycouldimprovethepatientexperience. Modernizingthedeliveryofcare,leveragingtechnology,andinnovationin healthcarearewellreceivedandhavebeenembracedbytheindustry. However,manyorganizationsareplaguedwithmisalignedbudgetsand incentivesystemswhichmakeitchallengingforinvestmentstooccur.

Hospitalbudgetstendtobeallocatedtohospitalunits:

• Clinicaldepartments-medicineandsurgery

• Careareas-emergencydepartmentsandoperatingrooms

• Ancillarydepartments-pathologyandpharmacy

Becauseofthiscompartmentalizedbudgetstructure,itcanbechallengingto findthemoneyneededtoinvestintechnology.Operatingbudgetsare notoriouslystrictaswell.Alackofseparationbetweenoperatingandcapital budgetprocessesfurthercomplicatesthesituation.

Consideringbudgetstructuresandconstraints,HIMleadersmustworkwith executivestofundmedicalrecordoptimizationtechnologies,suchas documentationaudits,tohelpreducedenialsandensureprovidersarefully reimbursedforservicesandrevenueiscontained.

Addressing the Hierarchical Condition Categories Gap

MostCDIprogramsdonotcurrentlyaccountforhowtheirpatient-centered approachaffectspatientacuity.Outsideofvalue-basedpurchasingfor

hospitals,theimportanceofinpatienthierarchicalconditioncategories(HCC) captureisundervalued.Asattestedbythisarticle,asignificantportionof patientsareassignedHCCsfromaccountablecareorganizations(ACOs)and notfromtheirprimarycareproviders.AsaresultofthelackofHCCsontheir patients,hospitalsloseoutonpayments.

Asof2016,58%ofHCCsarecomplications/comorbidities(CCs)ortheir majorvariants(MCCs).Assuch,accurateinpatientcodingcanleadtobetter outpatientcoding.ThiswillincreaseHCCcaptureratesandimprovetherisk adjustmentfactor(RAF).

Customized Inter-System Auditing and Updated EMRs

Today,healthcaresystemsincludephysiciangroups,acutecareenvironments, hospitals–bothsmallandlarge,multi-locationfacilities,andoutpatient settings.Healthinformationmanagementdocumentationauditswouldbe necessaryforeachsystem,dependingontheorganizationandbasedonhow besttoimprovecomplianceandreimbursements.

Electronicmedicalrecords(EMRs)cannowbeentereddirectlyastextand coded.Thissimplifiesthecodingprocessforproviders,butthelackof specificityinthecodeschosenmayresultinincorrectreimbursementand compliance.Inthefuture,HIMauditingpracticeswillhavetoincluderegular auditingofEMRstoensuremedicalcodersandautomatedsystemscode accurately.

HIMprofessionalswillcontinuetoplayapivotalroleinthehealthcare industryasitadoptsnewtechnologiestoensureproperreimbursementand compliance.

Source of content: AGSHealth Blog – The Future of HIM Audits