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Health
Information
Management
Overview
Meta Health Technology
16 January 2012
What is HIM?
© 2012, Meta Health Technology
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
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
Services provided
Clinical Documentation Improvement
Quality Care Support
 QA, UR, RM & Physician credentialing
© 2012, Meta Health Technology
© 2012, Meta Health Technology
Departmental structure
HIM Workflow (paper)
© 2012, Meta Health Technology
HIM Workflow (hybrid)
© 2012, Meta Health Technology
HIM Director
Privacy Officer
Compliance
Revenue Cycle
Medical Record Committee
Forms Committee
Performance Improvement
Budget & Finance
© 2012, Meta Health Technology
Coding
© 2012, Meta Health Technology
Credential: CCS All patient typesAccess to data Reimbursement
numeric code
780.60
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
Chart retrieval
© 2012, Meta Health Technology
all accounted for
assembly & filing
(paper charts)
Document management
© 2012, Meta Health Technology
Transcription
© 2012, Meta Health Technology
Sample Reports
24 hr turnaround
required
Discharge
summary
History &
Physical
Operative
results
work from
home
outsourcedor
Chart completion
© 2012, Meta Health Technology
Post Discharge
Analysis
Notification
Reporting
“Completed” =
Signed
Dictated
Transcribed
Joint Commission
(accrediting agency)
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
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 *
CDI
Clarify principal diagnosis
Capture MCC / CCs
Improve Documentation
© 2012, Meta Health Technology
Nurse RHIA / CCS CDI sheet
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
© 2012, Meta Health Technology
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Health Information Management Overview

  • 2. What is HIM? © 2012, Meta Health Technology
  • 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. 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. Services provided Clinical Documentation Improvement Quality Care Support  QA, UR, RM & Physician credentialing © 2012, Meta Health Technology
  • 6. © 2012, Meta Health Technology Departmental structure
  • 7. HIM Workflow (paper) © 2012, Meta Health Technology
  • 8. HIM Workflow (hybrid) © 2012, Meta Health Technology
  • 9. HIM Director Privacy Officer Compliance Revenue Cycle Medical Record Committee Forms Committee Performance Improvement Budget & Finance © 2012, Meta Health Technology
  • 10. Coding © 2012, Meta Health Technology Credential: CCS All patient typesAccess to data Reimbursement numeric code 780.60
  • 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. Chart retrieval © 2012, Meta Health Technology all accounted for assembly & filing (paper charts)
  • 13. Document management © 2012, Meta Health Technology
  • 14. Transcription © 2012, Meta Health Technology Sample Reports 24 hr turnaround required Discharge summary History & Physical Operative results work from home outsourcedor
  • 15. Chart completion © 2012, Meta Health Technology Post Discharge Analysis Notification Reporting “Completed” = Signed Dictated Transcribed Joint Commission (accrediting agency)
  • 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. 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. CDI Clarify principal diagnosis Capture MCC / CCs Improve Documentation © 2012, Meta Health Technology Nurse RHIA / CCS CDI sheet
  • 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. © 2012, Meta Health Technology Questions