Health Information Management (HIM) Standards

Revenue Integrity Standards and Accreditation in Healthcare

Health Information Management (HIM) Standards

HIM Summary

Measuring performance helps hospitals assess revenue cycle efficiency and effectiveness. Monitoring the HIM standards will help ensure that information is processed timely and in compliance.

Processing records post discharge becomes key in productivity and revenue impact. HIM processes are dependent on access to all clinical documentation and any CPT code charging via the charge master. HIM coders will require access to all areas where this data may be recorded. In the absence of a unified EMR, the coding function requires access to the paper chart and / or component systems used to document clinical care. Where an EMR is used, coders require access to view all of the areas within the EMR where documentation and coded data may be recorded.

Clinical coding involves complex rules and guidelines dependent on the patient status and location of care. Edits should be utilized in the coding department to assist coders with accuracy and compliance.

With the October 1, 2015 implementation of ICD-10 coding, hospitals will encounter challenges extracting specific details within physician documentation for code assignment, thus billing delays and potential denial increases. Monitoring coder productivity, chart delinquencies and performing internal and external coding audits will lead to maximized cash flow that is in compliance.

Successful hospitals utilize credentialed coders, arrange opportunities for continuing education credits, provide up-to-date abstracting and compliant systems, and administer internal and external coding audits to maintain the integrity of the coding process.

Monitoring standards will help hospitals identify areas of improvement needed and will assist in establishing measurements for progress.

HIM-01Certification for Coding Staff

HIM-01.01Goals will be set for all coding staff to obtain a coding certification from AHIMA or AAPC within one year of hire and maintain the certification while employed as a coder.

HIM-01.02Continuing education must be maintained in accordance with industry requirements for certified coders. Standards set will be documented in writing.

HIM-01.03Hospitals will be expected to show proof of continuing education for coding staff including progress in certification for those not already certified.

HIM-01.03Best Practice Standard is 100% of staff will have documentation of continuing education and certification progress.

Rationale for HIM-01

Coding accuracy is extremely important to healthcare organizations and has an impact on revenue as well as outcomes data. In order to achieve accuracy, a coder must be trained and continually educated. Coding requires the understanding of complex medical terminology as well as complicated coding rules. Certification demonstrates a coder’s proven knowledge and proficiency in coding. A credentialed coder must also maintain continuing education units which serves to reinforce their understanding and is essential to keeping abreast of the ever changing health environment.

Note:This standard should be tracked and monitored quarterly to ensure progress with continuing education. Records can be kept in the HIM department or in Human Resources.

Equation:N:Total number of coding staff meeting continuing education and certification requirements.

D:Total number of coding staff

Surveyors will request staff records for review and will request documentation of education tracking.

HIM-02Chart Delinquencies > 30 Days

HIM-02.01Hospitals will monitor and track all chart delinquencies that are aged greater than (>) 30 days from discharge.

HIM-02.02Tracking should include minimum information of at least: medical record number, date of discharge, chart hold reason, physician name and any effort made prior to and after 30 days to resolve chart hold.

HIM-02.03 Best Practice Standard is less than (<) 5% of charts will be delinquent > 30 days from discharge date.

Rationale for HIM-02

Charts should be completed, coded and sent to billing in a timely manner to ensure efficient revenue flow. Many payers have timely requirements that must be met in order for the hospital to receive payment. In addition, tracking these standards by physician and reason for hold will allow hospitals to determine where the process is and isn’t working.

Note:This standard should be tracked on a concurrent basis allowing education and process reviews to occur in real time for more efficient revenue flow

Equation:N:Total number of accounts on hold > 30 days afterdischarge.

D:Total number of discharged accounts

Surveyors will request the data for analysis and will request random charts for accuracy reviews. It is the responsibility of the hospital to collect and maintain data with documentation to verify the data collected.

HIM-03Inpatient Charts Coded Per Day

HIM-03.01Hospitals will monitor inpatient coding productivity and will track coder productivity daily.

HIM-03.02If a hospital has a low volume of charts, and the coders are responsible for both inpatient and outpatient coding, goals and standards can be tailored with surveyors in advance for tracking.

HIM-03.03Best Practice Standard is a minimum of 20 inpatient charts per day.

Rationale for HIM-03

Tracking coder productivity ensures that charts are being coded efficiently. Without productivity standards coders do not know what is expected and do not have goals to aspire to. Monitoring productivity allows hospitals to determine if goals are realistic and if there are other issues delaying charts for billing.

Note:This standard should be tracked daily with a cumulative total tallied weekly and monthly. A weekly and monthly tally grants flexibility for issues that coders may have tracking information, querying physicians and other duties.

Equation:Total of charts coded daily should be reported in a weekly and monthly format for evaluation of productivity standard.

Surveyors will request the data for analysis. It is the responsibility of the hospital to collect and maintain data with documentation to verify the data collected.

HIM-04External Coding Audits

HIM-04.01Hospitals will have an external audit performed on a sample of cases based on the hospital’s own audit goals, compliance risks, and/or coder feedback.

HIM-04.02If a hospital’s coding function is outsourced, then the hospital must verify that the agency has completed external audits and receive an explanation and confirmation of completed actions in response to findings.

HIM-04.03Best practice standard is to have an external audit performed at least annually.

Rationale for HIM-04

A hospital must understand the accuracy of their coding in order to avoid risks. Audits offer the ability to look at the department’s operations and processes. Coding audits can reveal compliance risks as well as revenue enhancement opportunities. AHIMA recommends annual external coding audits as an industry standard. External audits offer an objective review that may uncover deficiencies that an internal audit program may miss. Audits require proper preparation and management as well as effort to implement recommendations.

Note:This standard must be reviewed at least annually. External audits may be performed more than once per year, but at a minimum of once per year.

Equation:The measure is based on having completed at least one external audit within the calendar or fiscal year.

It is the responsibility of the hospital to ensure the audit has been completed to confirm the standard has been met.