Health Information Management
Health Information Management
Health information management is a discipline of recording, interpreting and safe keeping the digital and traditional medical data and information that is crucial to providing quality healthcare services to people. A coding manager is in charge of the coding activities in a healthcare facility. They oversee the other medical coding staff, maintain the patient records and ensure their security. A coding manager is also responsible for making changes and responsibilities in the health records and informatics department (AHIIMA, 2015a).
The responsibilities of the inpatient and outpatient coders in a healthcare organization include; reviewing the inpatient and the outpatients records and assign accurately diagnostic and procedural CPT-4 HCPCS or ICD-10-CM/ICD10-PCS and ICD-9-CM codes to the greatest specificity (ICD-10 Code Search, 2016), deriving demographic and coding information accurately, providing coding support in coverage of the staff and upgrade of the system among others. The coders should be aware of the medical terminologies to code accurately. Some of the information captured include; history of the medical condition or physical exam, clinical information, x-ray and other procedures among others.
The clinical documentation improvement program enhances accurate representation of a patient’s clinical information that translates to coded data (AHIIMA, 2015a). Recording of accurate data is important to both the hospital administration and the patients seeking healthcare services in hospitals. It provides information to all the healthcare providers and helps improve the quality of services being provided. The aim of the clinical documentation improvement program is a review of medical records and recording to increase the clarity, accuracy, and the provider specificity documentation. This is helpful as it reveals the clinical severity of the patient’s condition that impacts reimbursement and gives a justification for the utilization of the hospital’s resources on the patient.
CID programs provide collaboration between the coders and healthcare providers hence ensuring accurate, timely and reliable, relevant information. The program also enables healthcare facilities to increase their reimbursement hence more revenue. This is achieved through proper documentation of all the services accorded to a patient. Clinical documentation improvement program enhances collaboration between departments hence increasing the accuracy and reliability of health data. The program ensures compliance with policies developed to ensure quality data for improved healthcare services (AHIIMA, 2015a).
Evaluation of the qualification for potential candidates of coding is important so as to ensure the employees who get the job are qualified and they can deliver on their roles and responsibilities. First and foremost, the hiring organization should ensure that they have good recruitment practices and a favorable working environment. The roles and responsibilities of the coder should be identified and well defined so as to ensure that they know what is expected of them and perform as anticipated.
The potential employee should have the required minimum qualifications for a coder. Experience can be used as a factor to consider for employment. However, employers should not disregard people without experience especially the fresh graduates from school (Israel, 2012). Fresh graduates may not have the readily available experience needed, but they got the basic academic qualifications and are willing to learn. Evaluation of soft skills among the applicants is another way of ensuring that the potential employee is up for the task and will deliver as expected. Some of the soft skills to consider when hiring a coder would be; communication skills, good analytical skills, and collaboration among others. There is also need to identify and prioritize individuals with preferred qualifications such as certification on matters of coding for instance with the latest technology. This will ensure that the coder can adopt fast in the healthcare organization and is flexible.
Staff retention upon hiring is important for any organization so as to reduce turnover. Company executive leaders and strategists need to develop policies and programs that ensure that employees are retained in the organization upon hiring. One of the strategies is the provision of a favorable working environment. The environment should be safe for the employee especially for the individuals working in a hospital. Hospital administrators should ensure that there is equipment to reduce transmissions as they perform their duties. The supplies should include personal protective equipment. Health education should also be done. Continuous education should also be provided for the coders to ensure they are up to date with what is happening in their field and maintain the coding standards. This will ensure that quality data is generated.
The charge description master is a list of services and goods that can be billed to the patient upon completion of a visit to a healthcare facility. It gives a summary of the charges that the physicians and nurses have offered the patient during the visit. Depending on the level of a healthcare facility then the size of the charge description master will vary. Some healthcare facilities have very simple charge description master, and others have complex ones with many parts.
The CDM file contains a list of physician’s services and the cost of each special reference number among other information (e-Tampa Bay Associates, 2016). Effectively managing a charge description master is important for any organization offering healthcare services. It enables the organization to have and implement simple billing process and maintain revenue collection process. To establish an effective CDM, there is need to involve all the departmental heads in the health facility and ensure that all the regulatory and agreement requirements are met.
The charge description master (CDM) committee utilizes employees from the coding department, billing department and the CDM staff to ensure that the revenue cycle is maintained as it is effective. The billing department ensures that the CDM matches the contractual agreement of insurance companies so as to reduce complications occurring when dealing with them as well as ensure the system is user-friendly and effective.
The coders’ role is to ensure that they record all the services that patients receive in the hospital. Accurate and timely reporting and recording are important to capture the actual services so that the hospital can receive reimbursement (e-Tampa Bay Associates, 2016). The accurate information provides evidence for the work done and as such the CDM committee requires working with other departments to ensure that the hospital’s revenue process is working effectively.
Improving coding accuracy and coding productivity is every manager’s goal. Managers want to have a highly effective coding system, one that is responsive to the organization needs for timely and accurate data as well as effective revenue reimbursement. Strategies have to be developed to ensure that a healthcare organization is constantly monitoring and evaluating itself to identify gaps and come up with measures and strategies to make health informatics better in that particular institution (AHIIMA, 2015b).
Some of the strategies to ensure the development of accurate data would be the employment of qualified personnel. The policy developed should dictate the requirements for coders and should ensure that there is continuous education. The implementation will start at the hiring stage. The hiring process should be open and transparent to ensure only the best are employed. Continuous education for the coders should be conducted to ensure they remain highly competent. New technology is coming up every day, and for health informatics to remain effective managers there is a need for them to attend workshops and seminars to match up with the new technology. Continuous monitoring and evaluation will also help identify areas to improve.
In conclusion, health informatics is a diverse field that requires constant learning for all the participants to ensure that the resultant data is accurate and reliable. CDM committee should work with coders and the billing department to ensure availability of revenue. Coding managers should implement strategies that lead to the generation of accurate data.
AHIIMA. (2015a). Clinical documentation improvement. Retrieved from http://www.ahima.org/topics/cdi.
AHIIMA. (2015b). Health information 101. Retrieved from http://www.ahima.org/careers/healthinfo.
e-Tampa Bay Associates. (2016). Maximize revenues and increase patient satisfaction with a well-managed CDM file. Retrieved from http://www.e-tba.com/knowledge-center/CDM-whitepaper/index.html.
ICD-10 Code Search. (2016). ICD-10 coding. Retrieved from http://www.icd10codesearch.com/coding.php.
Israel, L. (2012). Seven steps to hiring the right coder. Retrieved from http://www.fortherecordmag.com/archives/121712p6.shtml.