HIM Onsite Assessment, Ongoing Phone Support and Optional Quarterly Onsite Follow-up
Objectives
To provide insight as to the HIM department workflow, timely completion of tasks, and interaction with providers as it relates to problematic documentation to support coding accuracy.
To review and provide education to the coders on the findings from the external audits if applicable– both on understanding the errors and reviewing patterns to eliminate repeat errors.
To provide ongoing phone support for all aspects of HIM issues – weekly calls.
To provide optional quarterly onsite intervention for all issues identified the HIM assessment and weekly calls.
To outline the continuing ‘at risk’ areas within the department and share at the conclusion of the onsite and thru a detailed Finding’s report.
Preliminary information HIM Assessment
DNFB weekly reports –leading to the Oct onsite and weekly thereafter
Productivity standards in place –per patient type
Unbilled per coder/per patient type
Others as identified prior to onsite
HIM Assessment – 2 to 3 days, depending on need and size of facility Onsite recommended outline
Onsite consultant/trainer will gain a high-level understanding of the HIM department through observation, informal conversation, and leadership meetings. The onsite will involve detailed work with the HIM staff, coding leadership, department leaders, CDI, and other ‘ripple’ departments.
Tentative Outline
Initial kick off meeting with HIM leadership as identified will occur to share updated information on the operations of the department. This is an open agenda that will help format the agenda for the onsite visit.
Meet the individuals within the department. A tour as well as an overview of the current workflow will occur by an individual within the department.
Begin the 1 on 1 coder observation and review of workflow, to also include provider practice team members, HIM staff and other department members. (Clerical, CDI, etc.)
Continued interviews with staff as well as other impacted leaders should occur.
The individual coders will be observed to assess workflow, current productivity concerns, EMR challenges that may be impacting coding, provider networking/adherence to requests, etc.
Feedback from the onsite consultant will include expectation of IT systems complexity that may be impacting productivity – national standards as well as improvement ideas for the site.
Individual department meetings that are impacting HIM or that HIM is impacting will also occur. These could be individual offices, registration, IT, PFS, etc. All areas will be reviewed to ensure ‘handoffs’ are known and included if ‘broken.’
Exit Summary/Discussion
A final exit meeting will occur with the HIM /other leadership to outline the observations and recommendations from the onsite. This may also include: Statistics for coder productivity, input on EMR issues, feedback from the coders on their concerns, staff competencies, feedback from providers and other impacted departments.
Finding’s report to compliment Exit Summary
A Finding’s Report will be submitted electronically within 2 weeks. It will include the items outlined above plus any other issues identified during the onsite.
Ongoing Phone Support – Post onsite
Weekly calls should be created with agendas submitted ahead of time along with a pre-determined day and time for each call. The date and length of the call will be logged and invoiced monthly.
Optional: Quarterly Onsite Follow-up Visits
As part of the ongoing HIM support program, quarterly onsite visits will be scheduled. Each visit will have general HIM issues but as ‘hot topics’ are addressed; an onsite agenda can be further developed. If additional onsite visits are requested beyond quarterly, a call will be scheduled to confirm and discuss.
A summary report of issues that were addressed including ‘going forward’ plans will be discussed with HIM leadership at the conclusion of each quarterly visit.