“Health information management (HIM) is the practice of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. It is a combination of business, science, and information technology.”
Health information management (HIM) plays a vital role in mapping a successful future for healthcare. Once limited to medical coding, data analysis, and other administrative tasks, HIM has expanded to cover medical technologies, information digitization, and the proliferation of wearables. All of these have created new avenues for obtaining patient-generated data and are redefining how we think of HIM.
As a result, the responsibilities of HIM professionals have expanded to include information security (to maintain the confidentiality of medical records), as well as conducting research and driving innovation.
HIM professionals support the continuous improvement of medical coding by curating data for patient records. Documentation audits help to identify gaps in patient records, which then allows HIM professionals to curate data from other systems to fill the gaps.
Errors in medical coding can lead to:
- False positives in Patient Safety Indicator (PSI) rates
- Blurred lines between active and resolved health conditions
- Reduce reimbursements
- Lost revenue due to claim denials
- Noncompliance with regulatory standards
All of these can be avoided with documentation audits, which identify and help to fill data gaps – reducing claim denials.
ICD-11 Brings 41,000 New Codes Contributing to Complexity
Medical providers and hospital executives understand that full reimbursement requires accuracy. Documentation audits are a crucial step in providers’ reimbursements. The transition to ICD-11 (International Classification of Disease, 11th version) will add a significant number of diagnoses, increasing from 14,000 in ICD-10 to more than 55,000 unique codes. Codes that medical coders will need to be aware of to prevent errors and missing documentation.
The transition to ICD-11 will require HIM professionals to monitor ICD-11 planning. Teams will need a clear understanding of the new