Health Information

ManagementOverview

Health Information

ManagementOverview

Meta Health Technology16 January 2012

What is HIM?What is HIM?

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Multiple healthcare settingsMultiple healthcare settings

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acute care & specialtyhospitals

physician offices& clinics

long-term care facilitiesrehabilitation &

ambulatory surgery centers

behavioral & mentalfacilities

government agencies &insurance companiesHIM

Services providedServices provided

Coding

Clinical coding (Inpatient & Outpatient: Op Dx, Obs, ED, AS)

DRG Analysis

Case mix analysis

Auditing

Compliance

HIM OperationsRelease of information

Chart completion

Chart assembly & filing (paper)

Storage & retrieval of medical records

Document imaging (hybrid/electronic)

Transcription

Tumor registry

Birth & death certification

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Services providedServices provided

Clinical Documentation Improvement

Quality Care Support QA, UR, RM & Physician credentialing

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Departmental structureDepartmental structure

HIM Workflow (paper)HIM Workflow (paper)

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HIM Workflow (hybrid)HIM Workflow (hybrid)

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HIM DirectorHIM Director

Privacy Officer

Compliance

Revenue Cycle

Medical Record Committee

Forms Committee

Performance Improvement

Budget & Finance

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CodingCoding

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Credential: CCS All patient typesAccess to data Reimbursement

numeric code

780.60

Coding: commonly used termsCoding: commonly used terms

DNFB (Discharged, Not Final Billed)

DRG (Diagnosis Related Groups)

Grouping

Diagnoses & procedures

ICD-9, ICD-10

CPT/HCPCS

Compliance, auditing, reporting

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Chart retrievalChart retrieval

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all accounted for

assembly & filing(paper charts)

Document managementDocument management

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TranscriptionTranscription

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Sample Reports

24 hr turnaroundrequired

Dischargesummary

History &Physical

Operativeresults

work fromhome

outsourcedor

Chart completionChart completion

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Post DischargeAnalysisNotificationReporting

“Completed” =SignedDictatedTranscribed

Joint Commission(accrediting agency)

Chart completionChart completion

“Record of Care” (RC) standardsHistory & Physical must be

completed within 24 hours of admission

Discharge summary completed & signed within 30 days of discharge

Operative report completed immediately after surgery

Physician orders time/dated & signed

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Release of information (ROI)Release of information (ROI)

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Log & track requests

Validate authorization

Retrieve information

Invoice requests

Release record in accordance with HIPAA & state statutes

Report “accounting of disclosures”

* The only revenue-generatingHIM function *

CDICDI

Clarify principal diagnosisCapture MCC / CCs Improve Documentation

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Nurse RHIA / CCS CDI sheet

Present CDI focusPresent CDI focus

Clarification of principal diagnosis

CC/MCC captureRevenue generation: case

mix increase; return on enhancement

Measurement: number of generated queries, physician response rate, impact on revenue

Review for RAC DRGs

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© 2012, Meta Health Technology

Questions