There should be a strong and healthy relationship between health information management (HIM) and case management and/or utilization review (UR) in every healthcare setting. These functions are part of the revenue cycle, but rarely interact. I believe that UR/case management can be helpful to HIM, and vice versa. My first HIM hospital position was in a teaching hospital. The UR/case management department was located next door, and we engaged in a lot of informal communication.
These departments should chat specifically about the collection of social determinants of health (SDoH) data. The discussion topics should include who is collecting the data, where is it documented, and which data should be coded. The answers will be different in each organization. Payors have initiatives centering on the SDoH, and it should be determined which initiatives are most important to your facility.
Another area of collaboration is medical necessity. Frequently, UR/case management will get pre-authorization for procedures based on a CPT code. It is important for the coders to be aware of which CPT code was pre-authorized. The coders can make the UR/case managers aware if a different procedure was performed. A new authorization may be needed, which could avoid a denial and expedite account payment. Coders may be able to assist UR/case managers when they need to assign a CPT code for a procedure. The interaction between them may also be helpful when assigning diagnosis codes to outpatient claims, if the diagnosis codes for medical necessity fail. Additional documentation may be needed from the provider to pass medical necessity, and UR/case management can learn from this process.
The coders may also utilize the clinical expertise of UR/case management. There are times, as a coder, that you may need some clinical input to your coding. The UR/case management staff may have different clinical backgrounds and be able to assist when clinical expertise is needed – and they can provide this clinical input when clinical documentation integrity staff is not available.
Another area where these professionals can interact is the discharge disposition. Providers may not document the precise type of facility to which the patient is being discharged. For example, consider a skilled nursing facility (SNF), but the patient was discharged to a licensed rehabilitation unit within the SNF. When in doubt regarding the discharge disposition, it is important to contact UR/case management to get the accurate type of facility.
I think it is important to have regular touch-base meetings. UR/case management staff may be aware of new procedures that are being proposed. HIM may communicate problems with provider documentation. Such a meeting provides an opportunity to discuss documentation trends and changes in medical practice. It is another way to informally communicate with the medical staff and keep a finger on the pulse of hospital activity.
UR/case management and HIM are two valuable revenue cycle departments. They can assist each other with their skills.
