Health care data are compiled and analyzed to reveal public health patterns and identify ways to better utilize resources and manage healthcare costs. Codes are used on hospital and physician reimbursement claims not only to describe diagnoses, services, and procedures provided but also for benchmarking measurements. Read further to understand why should you document and manage health care data and what are the frequent errors in data management.
Data management allows for examination of the documentation within the medical record to ensure the accuracy of the codes assigned and that no codes have been missed. It ensures adherence to coding and documentation standards, for example, as provided in: ICD-9-CM Official Coding Guidelines, Coding Clinic, Standards of Ethical Coding, CPT Assistant, Medicare Conditions of Participation, and the Joint Commission Information Management (IM) standards. It also assists in determining the appropriate reimbursement for care provided to patients. It assesses the quality of coding and documentation by individuals (i.e., coders, providers, and other healthcare professionals), and it identifies educational opportunities.
Roles and Responsibilities of Health Information Management
Clarify conflicting, ambiguous, or nonspecific information appearing in a health record by consulting the appropriate physician (physician query process). Participate in quality assessment to ensure continuous improvement in ICD-9-CM (soon ICD-10-CM/PCS) and CPT coding as well as collection of quality health data. Demonstrate ability to recognize potential coding quality issues from an array of data. Apply policies and procedures on health record documentation and coding that are consistent with official coding guidelines. Contribute to development of facility-specific coding policies and procedures.
Cons of Incomplete or Missing Data
The major cons of incomplete or missing data are it compromises on the patient care, it contributes to incorrect assumptions made by policy makers, and it can lead to inaccurate research findings.