The Future of HIM Audits

By AGS Health

August 23, 2022

“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 code set. Now is the time to begin promoting ICD-11 education, training, and workforce development. This will ensure your team is well prepared for the transition. If teams aren’t prepared it could lead to increased denials and a decrease in reimbursements.

By establishing clinical documentation improvement (CDI) teams, HIM departments can ensure clinical documentation capture is prioritized. Comprehensive inpatient and outpatient documentation audits allow for:

  • More accurate coding
  • Program reviews
  • Query integrity

This helps medical coders improve patient record keeping, facilitate timely claims payments, and drive better patient care.

Securing the Investment for Medical Record Optimization

According to a Technology Innovation in Healthcare Survey by HIMSS Media, 52% of respondents stated technology could improve the patient experience. Modernizing the delivery of care, leveraging technology, and innovation in healthcare are well received and have been embraced by the industry. However, many organizations are plagued with misaligned budgets and incentive systems which make it challenging for investments to occur.

Hospital budgets tend to be allocated to hospital units:

  • Clinical departments - medicine and surgery
  • Care areas - emergency departments and operating rooms
  • Ancillary departments - pathology and pharmacy

Because of this compartmentalized budget structure, it can be challenging to find the money needed to invest in technology. Operating budgets are notoriously strict as well. A lack of separation between operating and capital budget processes further complicates the situation.

Considering budget structures and constraints, HIM leaders must work with executives to fund medical record optimization technologies, such as documentation audits, to help reduce denials and ensure providers are fully reimbursed for services and revenue is contained.

Addressing the Hierarchical Condition Categories Gap

Most CDI programs do not currently account for how their patient-centered approach affects patient acuity. Outside of value-based purchasing for hospitals, the importance of inpatient hierarchical condition categories (HCC) capture is undervalued. As attested by this article, a significant portion of patients are assigned HCCs from accountable care organizations (ACOs) and not from their primary care providers. As a result of the lack of HCCs on their patients, hospitals lose out on payments.

As of 2016, 58% of HCCs are complications/comorbidities (CCs) or their major variants (MCCs).As such, accurate inpatient coding can lead to better Outpatient Coding. This will increase HCC capture rates and improve the risk adjustment factor (RAF).

Customized Inter-System Auditing and Updated EMRs

Today, healthcare systems include physician groups, acute care environments, hospitals – both small and large, multi-location facilities, and outpatient settings. Health information management documentation audits would be necessary for each system, depending on the organization and based on how best to improve compliance and reimbursements.

Electronic medical records (EMRs) can now be entered directly as text and coded. This simplifies the coding process for providers, but the lack of specificity in the codes chosen may result in incorrect reimbursement and compliance. In the future, HIM auditing practices will have to include regular auditing of EMRs to ensure medical coders and automated systems code accurately.

HIM professionals will continue to play a pivotal role in the healthcare industry as it adopts new technologies to ensure proper reimbursement and compliance.

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AGS Health


AGS Health is more than a revenue cycle management company—we’re a strategic partner for growth. Our distinctive methodology blends award-winning services with intelligent automation and high-touch customer support to deliver peak end-to-end revenue cycle performance and an empowering patient financial experience.

We employ a team of 12,000 highly trained and college-educated RCM experts who directly support more than 150 customers spanning a variety of care settings and specialties, including nearly 50% of the 20 most prominent U.S. hospitals and 40% of the nation’s 10 largest health systems. Our thoughtfully crafted RCM solutions deliver measurable revenue growth and retention, enabling customers to achieve the revenue to realize their vision.

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