The Role of HIM Professionals in the Revenue Cycle

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HIM professionals touch many functions of the revenue cycle.

As we continue this segment on health information management (HIM) in the revenue cycle, I’d like to share some thoughts I discussed at the recent Missouri Health Information Management meeting.

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When we think about the functions that compose the revenue cycle (see graphic):

financial counseling/pre-registration, pre-admission testing, access, case management, HIM and coding, and patient financial services (PFS) including CDM, we are already involved in each of them!  Often times we provide the data to develop the grid for procedure prices that are used by the pre-reg team to share with self-paying patients, we assess the pre-admission testing and the results to determine if the testing is related to the inpatient care,we work with access to clean the demographic data,case management uses our working DRG in some cases and we help both the internal and external case managers to obtain some of the clinical information needed to support the status, and of course, we’re connected at the hip with PFS to ensure the coding is consistent with the charges and that CDM driven charges are consistent with the coding and documentation in the record.

HIM has other skills that are ideally aligned with managing the revenue cycle. These include the following:

  1. Logistics experience
  2. Understand the importance of demographics accuracy at the front end
  3. Clinical understanding
  4. Coding knowledge
  5. Strive for coding and revenue integrity
  6. Recognize the difference between charges and reimbursement
  7. Data analysis
  8. Know how to read regulations and take them to the next level
  9. We can fight!

We’re a feisty bunch and no one can fight a coding denial better than we can!  So, that brings us to our next topic:  What are the characteristics of a good appeal letter?

  • Timeliness: It’s important to respond to a denial promptly, but not so quickly that we don’t give a solid argument.
  • Provide concrete proof that you are entitled to the payment based on the coding you submitted and supported by the clinical documentation. Give a detailed account of the treatment provided for the patient and cross-reference to the copy of the medical record attached.  Identify the sources for the codes that were submitted with the claim.
  • Involve the clinician if necessary, to augment your appeal content.
  • Cite relevant national coding guidelines, professional juried journal articles or materials from recognized coding authorities and medical societies.
  • Recognize that the goals for payers are different than those of providers. If the payer continues to deny the case and you believe your position is valid, escalate the appeal.

Finally, when it’s all said and done, ensure your claim system and the payer’s claim system reflects the final set of agreed-upon codes for data integrity and the patient’s profile purposes.

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Photo courtesy of: ICD10 Monitor

Originally Published On: ICD10 Monitor

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