Health Information Management

Topic: Provide coders with the tools they need to do the job

HIM-HIPAA Insider, April 3, 2007

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Patients admitted to hospitals today are sicker and require more testing, the results of which must find their way to patient records. You are fortunate if you work at a hospital where those results are online. But your coders still must search reporting systems to view the results they need if the results are not tied together in an electronic health record for the patient or in the folder for paper records.

Nursing documentation has added bulk to the record with the bifold and trifold flow records. Other computer-generated documentation, such as daily cumulative laboratory reports, adds to the size of paper patient records as well. Often, patient-care staff will "thin" or "debride" the record of information that is no longer pertinent to the patient's current plan. These thinned portions are not consolidated with the record upon discharge, thus initiating a search for the "missing in action" (MIA) components, which may include the initial history and physical, physician progress notes, and orders from early in the patient's admission. All of these are critical documents that the coder needs to properly assign the DRG.

Diligent monitoring of the receipt of discharges and all related components of the patient record is imperative for HIM department management. As part of the daily discharge reconciliation process, an individual within HIM must ensure that the department receives all discharges, ambulatory surgery encounters, and emergency department encounters each day.

One way to promote collaboration on providing HIM with all discharges on time is to distribute a notification of MIAs to the offending patient care area, that area's administrative leader, the chief financial officer, the risk manager, the compliance officer, and the performance improvement director.

The longer a record is missing from the control of HIM, the more likely it is to be permanently lost. It also increases the chances of lost revenue due to the inability to code the record, inappropriate handling of the protected health information, or documentation modifications.

For outpatient diagnostic coding, documentation is equally important and often more challenging to locate. Establishing processes to route the physician's paper order to the HIM department is often unsuccessful. These processes require too much human intervention and handling, which frustrates all parties involved. Ensure that the HIM department has received and validated orders before the physician performs any physician testing. Invest in scanners for each of the registration areas. Using this relatively inexpensive technology at each of the registration areas facilitates the capture of the order image in an order document repository.

However, achieving consistency in receiving completed orders and having them scanned to an accessible document repository requires collaboration with information technology, patient access (registration) personnel, and the ongoing training of the access or registration staff and physician office staff.

The lead coder may need to provide this educational program for the patient access staff in order to provide them with adequate training on ICD-9-CM codes. Some facilities routinely receive orders at least one day in advance of testing. These facilities can hire a coding professional to review the orders in advance for validity.

Editor's note: The above article was adapted from the new book Coder Productivity: Tapping your Team's Talents to Improve Quality and Reduce Accounts Receivable. For more information or to order, call 877/727-1728 or click here.

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