As we all ring in the new year and decade, there are plenty of “old” concepts to still pay attention too! I’m talking about the basics of Health Information Management (HIM) – the body of knowledge and operations that is primarily known to live mid-revenue cycle due to coding. However, HIM concepts and practices are actually pervasive to the entire revenue cycle as they support both data and documentation integrity.
Starting with patient matching/duplicate record reduction to the accurate documentation, collection & maintenance of clinical data. Followed by ensuring proper access, sharing and protection of heath data, and of course concepts of ethical documentation, coding and billing practices. It’s all there in fundamental HIM practices.
Deep in the realities of daily operational life, we Mid-Revenue Cycler’s tend to focus solely on the pure coding/billing through put (codes, edits, denials), with our eyes only looking up for quality initiatives during frontend CDI or backend Audits. This laser focus on just a subset of metrics can cause us to easily overlook a few basic HIM concepts that support the whole revenue cycle.
Here are some reminders on those traditional HIM basics with the potential to affect your revenue cycle efficiency and overall revenue integrity starting with Medical Record Completion:
- Alignment of Medical Staff bylaws, rules and regulations as well as facility patient care policies to regulatory documentation needs. This combined with leadership support and enforcement of those requirements will be a huge boost to your organization.
- Processes for efficient record analysis and record completion optimized in your EMR - including proper triggering events, automatic notifications to providers, and management tools/dashboards to know what is outstanding.
- EMR Clinical process workflows in alignment with documentation needs - ensuring templates, smart phrases, smart text, preference lists, order sets, etc. all have proper information governance to balance physician clinical needs with regulatory documentation requirements.
- Workflows for missing documentation still discovered at time of coding. We all remember the days of coding clerical staff maintaining spreadsheets of items to track down. What’s happening with your EMR set up to flag, route, and message on this in real time?
- Overall EMR set-up for how coders access the documentation present. Document review listings/links vs. digging through various views of the electronic record and ensuring those are set up correctly, and continuously updated to provide a complete medical record for coding. On a side note, this a large consideration if any computer assisted coding programs are in place.
Here at the Wilshire group, we have the experience to assist with operational improvements and EMR workflow evaluation/optimization. Contact us today, and let us share our experiences with you for sound building blocks in your HIM practice and revenue cycle.