The Role of HIM Professionals in the Revenue Cycle

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.

When we think about the functions that compose the revenue cycle: 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.

Programming Note

Listen to Rose Dunn report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. ET

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, AHIMA-approved ICD-10-CM/PCS Trainer

Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, is a past president of the American Health Information Management Association (AHIMA) and recipient of AHIMA’s distinguished member and legacy awards. She is chief operating officer of First Class Solutions, Inc., a healthcare consulting firm based in St. Louis, Mo. First Class Solutions, Inc. assists healthcare organizations with operational challenges in HIM, physician office documentation and coding, and other revenue cycle functions.

Related Stories

Confusion Reigns over Application of G2211

Confusion Reigns over Application of G2211

Although the effective date for billing Office and Outpatient (O/O) Evaluation and Management (E&M ) Visit Complexity Add-on Code G2211 was Jan. 1, the Centers

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →