Health Information Management

Changes coming for HIM in wake of healthcare reform

JustCoding News: Inpatient, June 9, 2010

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The Affordable Health Care for America Act, passed in late March, may leave many HIM directors scratching their heads. After all, sweeping reform must mean change is coming, but what will it look like?

“It will be a while until all of this is flushed out and there is a clearer picture for the impact on HIM or other healthcare professionals,” says Darice Grzybowski, MA, RHIA, FAHIMA, president of HIMentors, LLC, in Westchester, IL. After all, many of the provisions don’t go into effect for several years.

Understanding what is in the act is an important first step to figuring out what is on the horizon. Only then can HIM directors start to determine how to manage changes. For example, Congress took care of most of its electronic-health-record (EHR) -related legislation in the American Recovery and Reinvestment Act’s Health Information Technology for Economic and Clinical Health Act. However, the new healthcare reform legislation does address the topic briefly. Per the Affordable Health Care for America Act, the Department of Health and Human Services is responsible for studying and reporting on ways to increase EHR use among smaller healthcare providers, including recommendations for further legislation to increase funding.

Although EHRs are not a big part of the reform act, the administrative simplification provision is, according to Dan Rode, MBA, CHPS, FHFMA, vice president of policy and government relations for the American Health Information Management Association in Washington, DC. The administrative simplification provision will allow for easier and more timely updating of the HIPAA transaction code sets. A process to update the sets more regularly could be set up, as well as issue a uniform guide for the use of the transactions, both of which should be good changes, Rode says. “The industry has already finalized 5060, and we’re still trying to get to 5010,” Rode says. “And the guide could presumably eliminate many of the variances in how we report data on claims.”

However, these changes are unlikely to come sooner than the switch to HIPAA 5010, set to occur January 1, 2012, as part of the preparation for the changeover to ICD-10 on October 1, 2013. But once the changes do occur, the industry will be able to keep up with HIPAA transaction code set changes much more easily, Rode says. “They could come annually after that, with minor changes each year, as opposed to a huge switch as we are seeing when we move to 5010.”

A few new provisions for Medicaid may also look familiar. For example, the act mandates the use of National Correct Coding Initiative edits for Medicaid claims filed on or after October 1, 2010. It also contains provisions for the nonpayment of healthcare-acquired conditions for claims for discharges as of January 1, 2010.

And the reform will also have indirect effects on HIM departments—for example, the sheer volume of their work. That’s a lot more coding, a lot more requests for information, a lot more insurance companies to deal with, and a lot more transcription. In fact, it means a lot more of almost everything HIM staff members manage on a daily basis.

“Where there is more volume, there is more work,” Grzybowski says. “So there will be an impact on resources needed, which is unfortunate given the labor shortage already in existence for HIM.”
“Unfortunately, that problem will probably continue for awhile,” Rode says. “But hopefully as we move towards increased EHR capabilities, that may help. ICD-10 may also help to make coding easier and more accurate as well by eliminating vague codes.”

And that could be very important because the act contains provisions for uncovering additional fraud and abuse. Providers have seen in the past that when the government looks into reducing waste and abuse, HIM departments tend to see additional auditing activity. Grzybowski believes the act will be no exception. “An increased emphasis on conducting audits, internal and external, will occur as greater volumes mandate greater need for quality checks and controls,” she says.

Whether this will translate into new auditors or just increased volume by those already in existence remains to be seen. The government may simply expand the programs it already has (e.g., recovery audit contractors), Rode says. He also believes the government may focus on auditing for blatant fraud, as opposed to abuse in the form of coding errors.

Regardless, HIM departments will need to update their processes and increase their efficiency to keep up with patient volume increases, according to Grzybowski. This includes using technology to improve work flow and adopting electronic document management systems.

“Use of consultative and interim staffing resources should also increase due to both the labor shortage and the increasing use of technology,” Grzybowski says. “Overall change management skills will also be essential.”

HIM staff may come to appreciate the new emphasis on quality and good data, both of which highlight HIM’s role in managing information. Reform could also bolster hospital bottom lines, formerly hindered by receivable problems when patients couldn’t pay for care. “It could well stabilize healthcare organizations,” Rode says, “which will be a positive in the long run for everyone.”

Editor’s note: This article was originally published in the June issue of Medical Records Briefing. E-mail your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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