The Health Information Management (“HIM”) department is the informational and financial hub of healthcare facilities. Coders, clinical documentation specialists (“CDS”) and quality/compliance analysts are the last line in an important workflow that determines a facility’s reimbursement. An HIM directors’ responsibilities go beyond making sure things just run smoothly. A successful HIM director will optimize workflow, collaborate with providers to improve documentation, analyze data and respond to trends and findings of ongoing audits.
Here are factors to consider to ensure your department is as efficient and compliant as possible. This list can help those facing known backlog and workflow issues in addition to those who are looking to optimize workflow or uncover potential issues.
- Coding assignments – how are cases assigned? Many worklists are now automated through revenue cycle software. Assigning cases randomly in theory is a good practice but doesn’t take into account the clinical complexity of cases. Consider reviewing worklists (in addition to the automated process) to ensure your coders are receiving a balanced mix of complex cases. Reviewing the queue will prevent errors due to coder fatigue and backlog due to an unequal distribution of complex cases.We recommend reviewing lists for:
- Length of stay
- Discharge disposition
- Number of procedure codes (once the case is coded) to understand the complexity and time to code
- Type of service (e.g., trauma vs. a well-baby)
- Other factors adding to the complexity and length of coding a case
- Resource analysis based on case mix – Ensure you are setting reasonable productivity standards based upon your facilities case mix. General industry guidelines are a helpful start but do not account for differences between facilities. Many factors including environment (e.g., urban, rural, etc.), crime rates, seasons, trauma center designation, specialty units, etc. determine the case mix and volume. Do not conform to just any standard industry benchmark. Perform a real-time resource analysis and look at data such as total discharges, types of cases seen, number of full-time and contract coder full-time equivalents (FTE) current productivity rates and known backlog metrics. Any gap analysis should begin first with a realistic picture of the department before moving onto goals and more aggressive productivity targets.
- Queries – are your physicians responding to queries? Your backlog may be due to a non-response by physicians and this non-response may be due to several factors:
- Physician training – do they understand why they are being queried? Many physicians, unaware of coding guidelines, find certain queries clinically irrelevant or illogical. Train your physicians on high dollar, high frequency queries to help them understand how to prevent queries (i.e. proper documentation) and why they are being queried in the first place. For more information about query process improvement click here.
- Coder training – similarly, ensure your coders are writing clinically concise and informative questions.
- Clinical documentation specialists workflow and training – does your CDS team round regularly to catch documentation opportunities in real time? Do you have a clinical documentation team? Do they focus on the right high revenue/high frequency diagnoses and procedures? Do they educate the physicians on the floor or through in-services? Physicians are not the only parties at fault for query communication breakdown. Ensure there are no patterns in the types of queries missed by your CDS team through an internal audit process. The audits can uncover training opportunities on clinical guidelines and trends in repeat documentation issues.
- Escalation process – do you have an escalation process to ensure physicians are held accountable for their documentation and query requests? Similarly, is there a policy in place to inform coders of how long to hold a case before dropping an unanswered query?
- Conduct frequent audits to assess your coders’ performance – where are there training opportunities? Coder ‘x’ may shorten their coding time if they are trained on areas of weakness. Perhaps they need additional shoulder-to-shoulder training on ICD-10 concepts like fractures or procedure codes. Additionally, audits identify training needs around facility-specific policies and coding clinic guidelines. A thorough understanding of ‘what’ and ‘when’ to code will increase their productivity. Your supervisors and lead coders should review updated coding clinics and an audit will identify if that is occurring.
Finally, remember that the workflow of an HIM department, specifically the coding and documentation piece is largely clinical. Take into account the recommendations and suggestions of your clinical coding and documentation staff to ensure the workflow is optimized for them. The best practices of patient financial services and other business offices may not fit 100% with the department’s needs. Consider the clinical knowledge and training gaps, the complexity of cases and the documentation opportunities that may be holding your coders’ productivity back.