HIM’s Role in Revving up Revenue Integrity

Health information management professionals are fulfilling roles in numerous healthcare settings.

“Revenue integrity” is a relatively new buzz-phrase, but it certainly is a concept that should have been in practice since pay-for-service healthcare began. In essence, if it had been religiously practiced, the “fraud” would not be in the healthcare lexicon. At least that is the position I am taking in the new Revenue Integrity book I am preparing for the National Association of Healthcare Revenue Integrity (NAHRI), which will cover the topics in this article and more.

Achieving revenue integrity is an important goal for all revenue cycle leaders. By striving for it, we concern ourselves with correcting those practices, systems, and processes that create erroneous charges. Our goal should be to claim only those charges for which we are entitled compensation, and those that are supported by documentation in our records.

Roles in revenue integrity are popular these days. Nearly 9,500 revenue integrity position listings appeared on a popular recruiting website recently. The titles ran the gamut, including auditor, analyst, assistant director, director, educator, liaison, manager, nurse, and specialist. Clearly, the revenue integrity role is broad, and there is a growing need for professionals to fill these roles.

There are many initiatives that health information management (HIM) professionals can participate in to contribute to their organization’s revenue integrity endeavors.

Obviously, the first area is coding. Coding drives much of each claim, and accuracy will properly depict the conditions treated, but not necessarily the services delivered. The specificity of our coding contributes to the reimbursement defined by risk, prospective payment methodologies, and quality indicators.

Another area is the chargemaster. Individuals knowledgeable in chargemaster rules are hard to find. But how often do we see charges doubled on a claim, or a service that should be soft-coded being incompletely or inaccurately hard-coded by the charge description master (CDM)? Joining the chargemaster committee is a first step to contributing HIM knowledge to this process.

There are health information departments where the coding team codes services (including EKGs, radiology exams, and other services) that are routinely coded and charged by the CDM in other organizations. Why? It’s because these organizations trust the coding professionals more than the CDM. There is such a need for guidance in the chargemaster arena, making for a great opportunity for HIM professionals.

Another area where HIM can make a difference is with other charges that are applied through our patient care processes. Analyzing workflows and understanding logistics are often talents HIM professionals possess. Some HIM departments have taken on the duties of charge capture for the ED, OB, OR, and other departments. Doing so allows the patient care team to focus on patient care and allow HIM professionals to assume responsibility for accurate charge entry. Since data integrity contributes to revenue integrity, the organization benefits.

Achieving an environment of revenue integrity requires determination, detective skills, and the passion to ensure that your organization does what is right. HIM professionals can rev up the revenue integrity initiatives to do just that.