1. Health
Information
Management
Overview
Meta Health Technology
16 January 2012

2. What is HIM?
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3. Multiple healthcare settings
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acute care & specialty
hospitals
physician offices
& clinics
long-term care facilities
rehabilitation &
ambulatory surgery centers
behavioral
& mental
facilities
government agencies &
insurance companiesHIM

4. Services provided
Coding
Clinical coding
(Inpatient & Outpatient:
Op Dx, Obs, ED, AS)
DRG Analysis
Case mix analysis
Auditing
Compliance
HIM Operations
Release of information
Chart completion
Chart assembly & filing
(paper)
Storage & retrieval of
medical records
Document imaging
(hybrid/electronic)
Transcription
Tumor registry
Birth & death certification© 2012, Meta Health Technology

5. Services provided
Clinical Documentation Improvement
Quality Care Support
 QA, UR, RM & Physician credentialing
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6. © 2012, Meta Health Technology
Departmental structure

7. HIM Workflow (paper)
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8. HIM Workflow (hybrid)
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9. HIM Director
Privacy Officer
Compliance
Revenue Cycle
Medical Record Committee
Forms Committee
Performance Improvement
Budget & Finance
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10. Coding
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Credential: CCS All patient typesAccess to data Reimbursement
numeric code
780.60

11. Coding: commonly used terms
 DNFB (Discharged, Not Final Billed)
 DRG (Diagnosis Related Groups)
 Grouping
 Diagnoses & procedures
 ICD-9, ICD-10
 CPT/HCPCS
 Compliance, auditing, reporting
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12. Chart retrieval
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all accounted for
assembly & filing
(paper charts)

13. Document management
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14. Transcription
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Sample Reports
24 hr turnaround
required
Discharge
summary
History &
Physical
Operative
results
work from
home
outsourcedor

15. Chart completion
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Post Discharge
Analysis
Notification
Reporting
“Completed” =
Signed
Dictated
Transcribed
Joint Commission
(accrediting agency)

16. Chart completion
“Record of Care” (RC) standards
History & Physical must be
completed within 24 hours of
admission
Discharge summary completed
& signed within 30 days of
discharge
Operative report completed
immediately after surgery
Physician orders time/dated &
signed
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17. Release of information (ROI)
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 Log & track requests
 Validate authorization
 Retrieve information
 Invoice requests
 Release record in accordance
with HIPAA & state statutes
 Report “accounting of
disclosures”
* The only revenue-generating
HIM function *

18. CDI
Clarify principal diagnosis
Capture MCC / CCs
Improve Documentation
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Nurse RHIA / CCS CDI sheet

19. Present CDI focus
Clarification of principal
diagnosis
CC/MCC capture
Revenue generation: case
mix increase; return on
enhancement
Measurement: number of
generated queries,
physician response rate,
impact on revenue
Review for RAC DRGs
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20. © 2012, Meta Health Technology
Questions