Health Information Management Overview

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Health Information Management Overview

  1. 1. Health Information Management Overview Meta Health Technology 16 January 2012
  2. 2. What is HIM? © 2012, Meta Health Technology
  3. 3. Multiple healthcare settings © 2012, Meta Health Technology acute care & specialty hospitals physician offices & clinics long-term care facilities rehabilitation & ambulatory surgery centers behavioral & mental facilities government agencies & insurance companiesHIM
  4. 4. Services provided Coding Clinical coding (Inpatient & Outpatient: Op Dx, Obs, ED, AS) DRG Analysis Case mix analysis Auditing Compliance HIM Operations Release of information Chart completion Chart assembly & filing (paper) Storage & retrieval of medical records Document imaging (hybrid/electronic) Transcription Tumor registry Birth & death certification© 2012, Meta Health Technology
  5. 5. Services provided Clinical Documentation Improvement Quality Care Support  QA, UR, RM & Physician credentialing © 2012, Meta Health Technology
  6. 6. © 2012, Meta Health Technology Departmental structure
  7. 7. HIM Workflow (paper) © 2012, Meta Health Technology
  8. 8. HIM Workflow (hybrid) © 2012, Meta Health Technology
  9. 9. HIM Director Privacy Officer Compliance Revenue Cycle Medical Record Committee Forms Committee Performance Improvement Budget & Finance © 2012, Meta Health Technology
  10. 10. Coding © 2012, Meta Health Technology Credential: CCS All patient typesAccess to data Reimbursement numeric code 780.60
  11. 11. Coding: commonly used terms  DNFB (Discharged, Not Final Billed)  DRG (Diagnosis Related Groups)  Grouping  Diagnoses & procedures  ICD-9, ICD-10  CPT/HCPCS  Compliance, auditing, reporting © 2012, Meta Health Technology
  12. 12. Chart retrieval © 2012, Meta Health Technology all accounted for assembly & filing (paper charts)
  13. 13. Document management © 2012, Meta Health Technology
  14. 14. Transcription © 2012, Meta Health Technology Sample Reports 24 hr turnaround required Discharge summary History & Physical Operative results work from home outsourcedor
  15. 15. Chart completion © 2012, Meta Health Technology Post Discharge Analysis Notification Reporting “Completed” = Signed Dictated Transcribed Joint Commission (accrediting agency)
  16. 16. Chart completion “Record of Care” (RC) standards History & 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 © 2012, Meta Health Technology
  17. 17. Release of information (ROI) © 2012, Meta Health Technology  Log & track requests  Validate authorization  Retrieve information  Invoice requests  Release record in accordance with HIPAA & state statutes  Report “accounting of disclosures” * The only revenue-generating HIM function *
  18. 18. CDI Clarify principal diagnosis Capture MCC / CCs Improve Documentation © 2012, Meta Health Technology Nurse RHIA / CCS CDI sheet
  19. 19. Present CDI focus Clarification of principal diagnosis CC/MCC capture Revenue generation: case mix increase; return on enhancement Measurement: number of generated queries, physician response rate, impact on revenue Review for RAC DRGs © 2012, Meta Health Technology
  20. 20. © 2012, Meta Health Technology Questions

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