The Future of HIM Audit

Health information management (HIM), plays a crucial role in the healthcare industry, and mapping the future of the discipline is paramount. In the past, the scope of HIM focused on medical coding, data analysis, and other managerial functions. However, new innovations in connected medical technologies, information digitization, and the proliferation of devices such as wearables and fitness trackers have created new avenues of procuring patient-generated data and pushed the boundaries of HIM. As a result, HIM professionals are gradually branching out into information security — maintaining the confidentiality of medical records — as well as research and innovation.

In the midst of this ever-changing scenario, the primary target of HIM professionals remains the betterment of medical coding. Leaders in HIM are aware that inadequate medical coding can lead to complications in recording care codes, false positives in Patient Safety Indicator (PSI) rates, and blurred lines between active and resolved health conditions. Not only can this lead to lost revenue and increased claim denials, but also higher compliance risk for healthcare facilities. A lack of resources and clashing priorities coerce many healthcare providers to compromise their attention towards coding compliance programs.

Documentation Audits As Important As Coding Audits

Specificity is crucial to accurate reimbursement, making both auditing and documentation audits important to the success of healthcare providers. With the release of of ICD-10 (International Classification of Disease, 10th version), medical coding became more expansive to better encompass the conditions that afflict patients. With over 71,000 procedure codes, ICD-10 put medical coding under the spotlight. However, HIM departments have ensured that detailed documentation is prioritized through the implementation of clinical documentation improvement (CDI) teams in healthcare organizations. ICD-10 was launched with the purpose of capturing events, procedures, and device-related data in nuanced detail to facilitate accurate medical documentation.

Comprehensive inpatient and outpatient documentation audits will lead to accurate coding, program reviews, and increased integrity of queries. This will also allow medical coders to improve patient record keeping, facilitate timely claims payments, and better patient care. Documentation auditing will take centerstage in the future and HIM professionals will be at the heart of this development.

Prioritizing Reimbursement Optimization

According to a Technology Innovation in Healthcare Survey by HIMSS Media, 52% of respondents stated that patient experience can be improved by technology. The healthcare industry seems open to innovation but it has been plagued by misaligned budgeting and incentive systems.

Hospital units — clinical departments (such as medicine and surgery), care areas (such as emergency departments and operating rooms), and ancillary departments (such as pathology and pharmacy) — are largely unconnected and have their own costs and budgets. Due to this siloed structure, it becomes difficult to adopt cost-intensive innovations— it could take a bite out of the unit budgets that are probably already overstretched.

Operating budgets are notoriously rigid too and the consequences can be felt the year round. There is also a lack of separation between operating- and capital-budget processes. In light of such increasing budgetary constraints, it is imperative for HIM leaders to optimize reimbursement processes for hospitals.

Planning for ICD-11

The upcoming version of the international classification of diseases, ICD-11, is already online and inviting suggestions from coders, HIM personnel, healthcare providers, researchers and other interested parties from around the world for feedback, improvement, and even translation into other languages. Getting an audit program in place immediately will sustain audit quality and make the impending transition easier.

With the advent of ICD-11, HIM leaders will look to focus more on risk adjustment which will ensure a more accurate capture of hierarchical condition codes (HCCs). At present, most CDI programs do not account for how their patient focus impacts patient acuity. The importance of inpatient HCC capture is not seen as much outside of value-based purchasing for hospitals. A significant portion of patients are assigned HCCs from accountable care organizations (ACOs) and not from their primary care provider, as attested by this article. As such, hospitals lose out on payments from the lack of HCCs on their patients.

Since 58% of HCCs are also complications/comorbidities (CCs) or their major variants (MCCs) as of 2016, accurate inpatient coding can lead to better outpatient coding. This will increase HCC capture rates and improve the risk adjustment factor (RAF).

With the level of reimbursement at risk beyond conventional fee-for-service models, hospitals need to consider taking a long term view of risk adjustment. HIM auditing will have to account for the same in the coming years.

Customized Inter-System Auditing and Updated EMRs

From physician groups, acute care environments, hospitals to even outpatient settings, healthcare systems take on a variety of forms today. Depending on the organization, health information audits for every one of these systems would differ based on the unique factors that will facilitate improved compliance and reimbursements. For instance, a cost-based reimbursement model would suit a hospital more than audit results based on Medicare Severity Diagnosis Related Group (MS-DRG) reimbursements.

Electronic medical records (EMRs) can now be directly entered as text and mapped to codes. This make the coding process easier for providers, but the lack of specificity in the selected codes may lead to improper reimbursement and compliance. HIM auditing practices in the future will have to incorporate regular auditing of EMRs to make sure that coding by both medical coders and the automated systems are accurate.

HIM professionals will continue to play a pivotal role in the healthcare industry as it adopts new technologies to ensure proper reimbursement and compliance.

2019 OHIMA Annual Meeting

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Hardik Kevadiya

Hardik Kevadiya

Hardik Kevadiya is a Senior Manager, Business Development and Marketing at EZDI, Inc. - an AGS Health Company. Hardik is passionate about Healthcare Information Technology and Innovations - Innovations that enhance human lives. He is also a healthcare trend and news follower, his passion for helping Healthcare IT professionals in all aspects of online trends and research flows through in the expert industry coverage he provides. In addition to writing for EZDI, Hardik also mentors a team of Data Analysts and Marketing professionals.

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