Information Governance includes the Core Record Set for Coding Compliance Bonnie S. Cassidy, MPA, RHIA, FHIMSS

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1 Information Governance includes the Core Record Set for Coding Compliance Bonnie S. Cassidy, MPA, RHIA, FHIMSS DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS Has no real or apparent conflicts of interest to report HIMSS

3 Learning Objectives 1. Identify the roles and importance of information governance and data stewardship 2. Differentiate between the legal medical record and the designated record set 3. Describe the significance of Information Governance in ICD9 and ICD-10 Coding Policies 4. Explain the need for defining core set of medical record documents that are used consistently as the source of information for Coding 5. Create a culture of collaboration for Information Governance that provides a clear understanding of its importance and engages all stakeholders

4 AGENDA 1. Information Governance and Data Governance 2. Information Governance must include your Coding Policies/Playbook 3. Embracing the Clinical Documentation Record Set for Coding Compliance * There is a need for defining core clinical documentation set of medical record documents that are used consistently as the source of information for Coding. 4. Create a culture of collaboration for information governance.

5 Information Governance and Data Governance

6 Current State: Information Governance Our story as Health Information professionals is one of protecting and managing health information. Our primary ethical obligation to protect patient privacy and confidential information which includes: Oversight of disclosure of information; Management of Health information systems and health records; & the Quality of information.

7 Information Governance Is the responsibility of executive leadership for developing and driving the IG strategy throughout the organization. IG encompasses both data governance (DG) and information technology governance (ITG). Information governance provides parameters based on organizational and compliance policies, processes, decision-rights and responsibilities. Information Governance functions and stewardship ensures the use and management of health information is compliant with jurisdictional law, regulation, standards, and organizational policies.

8 Information Governance Information governance is emerging as a priority for healthcare. Information governance (IG) is the accountability framework and decision rights to achieve enterprise information management (EIM). EIM is defined as the infrastructure and processes to ensure the information is trustworthy and actionable

9 Information Governance Information governance is the high-level, corporate, or enterprise policies or strategies that define the purpose for collecting data, ownership of data, and intended use of data. Accountability and responsibility flow from governance. The Information Governance plan is the framework for the overall organizational approach to data governance. Article citation: Fernandes, Lorraine; O Connor, Michele. "Data Governance and Data Stewardship: Critical Issues in the Move Toward EHRs and HIE, JAHIMA, 80, no.5 (May 2009):

10 Data Governance Data governance (DG) is the responsibility of the business unit. It is the policies, processes and practices that address the accuracy, validity, completeness, timeliness and integrity of data (data quality).

11 Information Technology Governance Information technology governance (ITG) is led by the CIO. ITG is the process to ensure the effective evaluation, selection, prioritization, and funding of competing IT investments. ITG oversee the implementation and extracts (measurable) business benefits.

12 Why is Information Governance Important? Studies have shown that organizations with a formal governance program have an: 81% better decision making process, 85% improved ability to protect sensitive data 53% improved business results and; improved organization learning about information management.

13 Information and Data Governance must include your Coding Policies/Playbook

14 Data Governance is NOT an Afterthought Understanding the relationships between data is often difficult, and the rewards of adequately resourcing data stewardship are not always self-evident. It is often shuffled aside when its impact is not understood. A well thought out Information Governance Model that addresses many of the issues and clearly articulates organizations, systems, inputs, updates, appends, ownership, access, and reporting capabilities is the first step in an effective data governance program.

15 Information and Data Governance Information Governance acts as a framework for data that will be used to drive clinical and operational information and decisions; it is the blueprint for building a solid data structure. This blueprint should also include details about which systems generate which data, where data flow and how, and how data will be used.

16 Data Governance and Stewardship Data stewardship focuses on the people, policies, processes, and tools that manage the quality of data. It is the operational component that complements the data governance plan and ensures that data are fit for its intended purposes. Article citation: Fernandes, Lorraine; O Connor, Michele. "Data Governance and Data Stewardship: Critical Issues in the Move Toward EHRs and HIE, JAHIMA, 80, no.5 (May 2009):

17 Information Governance: Must include your Coding Compliance Plan It does not matter if your medical record is paper-based, hybrid or electronic, a high integrity Coding Compliance Policy should be written, updated at least once per year as part of your information governance framework. Your core designated clinical documentation set for coding should to be used as the key constant source of clinical documentation by your coding professionals as they conduct all the medical coding for your organization.

18 Risk in not having Information Governance Incomplete/incomprehensible health records Inconsistent clinical documentation and associated coding Inability to access and use information Privacy and security breaches Inability to effectively exchange information Copy/paste concerns that lead to fraud and abuse allegations

19 Embracing the Core Clinical Documentation Record Set for Coding Compliance

20 Coding Compliance begins with defining your Core Clinical Documentation Record Set Coding Compliance Policy: Do you have this? Job Descriptions, Productivity expectations, Quality monitors in place? Dust it off and complete an evaluation for Test it to the upcoming challenges in clinical documentation and associated coding that face the health information management (HIM) professional staff of 2013 and 2014 in your organization.

21 Coding Compliance begins with defining your Core Clinical Documentation Record Set Note: It does not matter if your medical record is paperbased, hybrid or electronic, a high integrity Coding Compliance Policy should be written, updated at least once per year as part of your information governance framework. Your core clinical documentation record set for coding compliance should to be used as the key constant source of clinical documentation by your coding professionals as they conduct all the medical coding for your organization.

22 Coding Compliance begins with defining your Core Clinical Documentation Record Set The collection of accurate and complete coded data is critical to healthcare delivery, research, public reporting, reimbursement, and policy-making. The integrity of coded data and the ability to turn it into functional information requires all users to consistently apply the same official coding rules, conventions, guidelines, and definitions (the basis of coding standards). Use of uniform coding standards reduces administrative costs, enhances data quality and integrity, and improves decision-making all of which leads to quality healthcare delivery and information...from the AHIMA Position Statement

23 Coding Compliance begins with defining your Core Clinical Documentation Record Set The AHIMA Position Statement ends with the following: For the U.S. to maintain quality data and information, coding standards must be consistently required, promoted, and uniformly applied across sites of service... Complete, clear, and accurate health record documentation is the foundation for complete and accurate coding. Therefore, this documentation, whether electronic or paperbased, must be clear, accurate, complete, and timely in order to produce quality coded data.

24 Coding Compliance begins with defining your Core Clinical Documentation Record Set To meet the spirit of the position statement, all HIM Coding professionals understand and adhere to report only the codes that are clearly and consistently supported by authenticated clinical documentation in accordance with code set rules and guidelines.

25 Coding Compliance begins with defining your Core Clinical Documentation Record Set Organizations must have formal policies and corresponding procedures in place that provide instruction on the entire process from the point of service to the billing statement or claim form.

26 Coding Compliance begins with defining your Core Clinical Documentation Record Set Coding compliance policies serve as a guide to performing coding and billing functions and provide documentation of the organization s intent to correctly report services.

27 Coding Compliance Plan Source of the official coding guidelines used to direct code selection The parties delegated with responsibility for code assignment The procedure to follow when the clinical information is not clear enough to assign the correct code

28 Coding Compliance Plan Specification of the policies and procedures that apply to specific locations and care settings. Official coding guidelines for inpatient reporting and outpatient or physician reporting are different. This means an organization that is developing a facilityspecific coding guideline for emergency department services should designate that the coding rules or guidelines that apply only in this setting.

29 Coding Compliance Plan Procedures for correction of inaccurate code assignments in the clinical database and to the agencies where the codes have been reported Areas of risk that have been identified through audits or monitoring. Each organization should have a defined audit plan for code accuracy and consistency review, and corrective actions should be outlined for problems that are identified.

30 Coding Compliance Plan Identification of essential coding resources available to and used by coding professionals A process for coding new procedures or unusual diagnoses A procedure to identify any optional codes gathered for statistical purposes by the facility and clarification of the appropriate use of E codes Appropriate methods for resolving coding or documentation disputes with physicians

31 Coding Compliance Plan A procedure for processing claim rejections A statement clarifying that codes will not be assigned, modified, or excluded solely for the purpose of maximizing reimbursement or avoiding reduced payment. Clinical codes will not be changed or amended merely because of either physicians or patients request to have the service in question covered by insurance. If the initial code assignment did not reflect the actual services, codes may be revised on the basis of supporting documentation

32 Coding Compliance Plan The use of and reliance on encoders within the organization. Coding staff cannot rely solely on computerized encoders. Current coding manuals must be readily accessible, and the staff must be educated appropriately to detect inappropriate logic or errors in encoding software. When errors in logic or code crosswalks are discovered, they are reported to the vendor immediately by the coding supervisor.

33 Coding Compliance begins with defining your Core Clinical Documentation Record Set Medical records are analyzed and codes selected only with complete and appropriate physician documentation available. According to coding guidelines, codes are not assigned without supporting documentation from the provider.

34 Coding Compliance begins with defining your Core Clinical Documentation Record Set Your Coding Compliance Plan should state that the entire record should be reviewed to determine the specific reason for the encounter and the conditions treated. What has never been clearly and uniformly defined are the actual core medical record documents or clinical documentation that should be used as the Core Clinical Documentation Record Set for Coding Compliance as the designated record and clinical documentation set for all coding.

35 Coding Compliance begins with defining your Core Clinical Documentation Record Set Your Coding Compliance Policy must identify medical record documents and clinical documentation that require a mandatory review by your coding staff and/or the outsourcing providers of coding for your organization.

36 Assess your current state 1. Understand the types of clinical documentation capture 2. Know the technology that will be affected by CAC and/or other ICD-10 preparations within your organization 3. Review your current workflow

37 Understand Clinical Documentation Types that Coders must access Document types Electronic Unstructured Structured (templatedriven) Scanned Hand-written Document formats RTF, TXT, PDF

38 Paper/Hybrid/EHR? How READY is my environment? Lab, Radiology Physician documentation ED Record H&P Progress Notes Orders OR Report Discharge Summary Medication Administration Document types Electronic Unstructured Structured (templatedriven) Scanned Hand-written Document formats RTF, TXT, PDF

39 Clinical Documentation Record Set for Coding Compliance INPATIENT Face sheet Progress notes History and physical (H&P) Discharge summary Consultation report Operative report Pathology report Laboratory report Radiology report Nutritional assessment Physician s orders

40 Clinical Documentation Record Set for Coding Compliance AMBULATORY Diagnostic services Therapeutic services Outpatient or ambulatory surgery Observation Emergency Department Therapies Problem list Medication list

41 What Technology will have an impact on your Coding Compliance Strategy Has your legal medical record been defined? Where does it exist paper or electronic? What other systems are in place? Clinical Financial Dictation/transcription/speech recognition Encoder Scanners Interfaces CAC What IT resources are available?

42 Transition from Management of Paper to Management of Data Integrity Drive development of standards: Patient identity management Protocols for amendments and retractions Naming conventions for forms and templates Build in time between phases for improvement/optimization Design 24/7 real time data integrity and clinical documentation improvement processes Communicate importance of and changes to legal medical record in electronic environment

43 Creating a culture of collaboration for Information Governance

44 Call to Action: Information Governance Information Governance is a Critical Role Many agreed this was due to the fact that providers aren t yet using the information to the degree that they will have to in the future In addition, as clinical outcomes data increases in importance with VBP, Information Governance will increase in importance.

45 Current State: Information Governance There is a clear need in the healthcare industry to move toward a standard approach to developing the policies for a uniform and consistent method for health data integrity and exchange that transitions the concept of data ownership to that of access, use, and control of data.

46 National Initiatives Health data stewardship has taken on great practical urgency because of the increase in availability of electronic health data; growing recognition of the value of electronic data in improving health care and population health; the acceleration in the use of information and communication technology; and awareness of the potential risks associated with incorrect or inappropriate uses of health data

47 National Initiatives Why Now? Many healthcare organizations have embraced data quality for years, if not decades, but the planning component of data stewardship and information governance is a relatively new concept in the health care industry. Formal data governance requirements are being driven by the explosion of electronic data, the consolidation in the healthcare provider arena, and the increased focus on data sharing within and across local, regional, and state levels.

48 Information Governance Information governance is the high level organizational framework or enterprise-wide infrastructure of accountability and responsibility that define the purpose for collecting data, ownership of data, and intended use of data. One of the critical success factors within this domain is Data stewardship which addresses the detail of data quality management, everything from process workflow, policies and procedures to project management within this space.

49 Coding Compliance and Information Governance Integrity of health information is an obligation for health information professionals. All health information professionals must assume a leadership role in transforming these functions. Now is the time to analyze and visualize documented and undocumented intra- and interdepartmental HIM functions to understand the current and future state of the HIM department while ensuring HIM best practices and standards are consistently maintained.

50 Call to Action: Information Governance Our challenge: Put your stake in the ground and let it be known in your organization that you are the steward of the data. Your organization can count on you and your team for world class Information Governance. Unified Data Governance principles will help promote accuracy and consistency and reduce ambiguity.

51 Supply chain Financial Clinical Value in having Information Governance Integrity of information Patient care Security Subsequent uses Predictive analysis Staffing Supply chain Financial Clinical Ability to exchange health information

52 Summary Create your Information Governance Model: IG, DG, ITG Define your Core Clinical Documentation Record Set for Coding Compliance Document your Coding Compliance Plan Understand the different types of clinical documentation capture Know the technology that will affect your ICD-10 Transition Strategy Review your productivity standards: current & future Assess your process for coding compliance

53 Thank You! Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS & AHIMA Approved ICD-10CM/PCS Trainer Senior Director of HIM Innovation NUANCE COMMUNICATIONS, INC. One Wayside Road Burlington MA Office Mobile

54 References AHIMA Thought Leadership Series: Defining the Core Clinical Documentation Set for Coding Compliance,October AHIMA, Embracing CAC Beyond Reimbursement Initiatives, Journal of AHIMA, (November/December 2012): pages AHIMA. "Data Quality Management Model (Updated)." Journal of AHIMA 83, no.7 (July 2012): AHIMA, Audio Webinar, ICD-9-CM Diagnostic Coding Guidelines for Outpatient Services, October 19, AHIMA Coding Practice Team. Developing a Coding Compliance Policy Document. Journal of AHIMA 72, no. 7 (Jul. 2001): 88A C. AHIMA House of Delegates, AHIMA Standards of Ethical Coding September Available online at, at

55 References AHIMA. Managing an Effective Query Process. Journal of AHIMA 79, no. 10 (Oct. 2008): AHIMA Practice Councils (Clinical Terminology/Classification, Quality Initiatives/Secondary Data). Understanding HACs and SREs for Quality Reporting and Reimbursement. Journal of AHIMA 80, no. 9 (Sept. 2009): AHIMA Transitioning Coding Professionals Into New Roles in a Computer-Assisted Coding (CAC) Environment, blog posted on AHIMA Blog. Comfort, Angela D., and Linda Schwab. Facility Specific ICD-9-CM Coding Guidelines. AHIMA audio seminar. October 30, Available online at Healthcare Terminologies and Classifications: An Action Agenda for the United States. White paper jointly released by AHIMA and the American Medical Informatics Association, Available at US Must Adopt and Implement ICD-10-CM and ICD-10 PCS. AHIMA position statement, Available at For more on ICD-10, see also

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