Case Histories

CLINICAL DOCUMENTATION, CODING AND BILLING SERVICES
HSMN was asked by well known Medical Center Complex in the Mid-Atlantic region to review the HIM (Medical Record infrastructure), review revenue issues related to documentation and coding of cases, and finally find out what kind of HIM structures, systems and processes would best support the Medical staff.

• HSMN provided this client with three engagements, since there were distinct clients within the request.
• The Medical Staff and each of the clinical departments were unhappy with the state of the medical record and the untimely availability of clinical data.
• Finance was concerned about denials, net revenue, accounts receivable, and cash flow.
• Administration was concerned about the lack of competencies and the lack of direction for Hospital Information.
• HSMN performed an analysis of the total infrastructure of HIM and whatever infrastructure existed in each of the clinical departments.
• HSMN evaluated the clinical data needs of each clinical department and rounded with physicians to find out about their needs.
• HSMN worked closely with IS/IT to understand what the mandates and resources were for putting information on line to be used in a growing enterprise on multiple sites.
• HSMN carefully reviewed the roles, functions, processes and systems that affected the hospital’s revenue stream.
• HSMN assisted the hospital in putting its key documents on line using an outsource company for transcription.
• HSMN began direct supervision of the coding processes, retraining coders and working with Medical Staff on Documentation Education.
• HSMN revised the roles and processes for the movement and completion of records moving toward greater automation.
• HSMN created new job families, organizational structure and leadership for HIM.
• At the same time, HSMN worked with a representative group of faculty members to reach consensus on a standard for a “Truly Electronic Record.”
• HSMN worked with IT to help move resources to automating clinical information availability.

OUTCOMES:

• There were significant improvements to net revenue and denials.
• Coding productivity and accuracy improved very dramatically.
• The HIM staff began to view themselves in a professional light that helped enhance their performance.
• The Medical Staff, working with IS and a work group, created an Electronic Patient Record that has won an award.
• The new infrastructure and leadership are working well.