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Blog | In Record Time, Inc. | 1-800-788-4960

In Record Time, Inc. is pleased to announce its 20th anniversary partnering with countless organizations to provide coding, abstracting, auditing, oncology data management, ICD-10 training,revenue cycle management, and HIM clerical services. The company is honored to be able to recognize this milestone, and it celebrates the clients that have made the company’s success possible.

In Record Time established its humble roots in 1995 during a time when organizations were just starting to transition their medical record departments to health information management departments. In a paper-based world, In Record Time assisted clients with assembly and analysis of paper records as well as loose filing. As organizations transitioned to electronic health records, In Record Time responded by providing scanning functions and top notch coding services via a secure remote platform. As third-party auditors increased their volume of audits and scrutiny of documentation, In Record Time responded by auditing clients with that same level of detail and also implementing an internal QA process to ensure consistency and accuracy. As HIM departments shifted their attention to ICD-10, In Record Time responded by providing back-up coding support, dual coding services, and thorough ICD-10 training for its own credentialed coding staff.

In Record Time knows that the world of HIM is in constant flux and that clients need a partner that can adapt to change quickly while providing cost-effective services.

 “I think HIM is a very dynamic industry. You can always expect the unexpected. We’ve had the foresight to evolve and change with that,” says Renee Klarberg, MPS, RHIA, who originally founded the company after having worked in various large acute care hospitals for many years.

What began as a small enterprise, In Record Time has grown exponentially, and its dynamic team boasts highly-experienced and credentialed coding and compliance personnel, certified tumor registrar professionals, and seasoned HIM operations and information technology staff, all of whom are based in the United States.

Although In Record Time has evolved commensurate with technology, the customer service principles on which the company was founded remain the same. Since its inception, the company has provided personalized and high-quality services based on a foundation of open and honest communication. Each client is unique, and In Record Time strives to provide services that can easily be adapted to changes in staffing and coding volumes.

“We’re very old fashioned in a sense. My biggest rule is that you always have to respond to your client within 24 hours,” says Douglas L. Klarberg, JD, vice president, who followed in Renee’s footsteps when he joined the family business in 2008. “We pride ourselves in building solid relationships with our clients, and we take these relationships very seriously. Our number one priority is to work hard and provide the highest quality services to our clients.”

Looking ahead to ICD-10

In Record Time understands the workflow and staffing challenges inherent in ICD-10. Using a proprietary tool, In Record Time can accommodate workflow fluctuations associated with ICD-10 and provide ample coding support during a time when productivity is expected to decrease significantly.

“Our expertise in being able to help clients gear up quickly for very large projects is an asset when it comes to ICD-10,” he says. “We also have an extensive network of coders with whom we’ve worked over the years. We’re constantly sourcing and testing candidates as well.” 

In Record Time also knows that there continues to be many unknowns with ICD-10. How will it truly affect coding productivity in a live environment? Will the volume of queries increase? What will happen if denials are on the rise? 

“Just as we’ve adapted to change in the past, our approach to ICD-10 will be no different. We’ll work right beside our clients to ensure their success. It’s a team effort, and we’re there to provide all of the support that our clients need,” he adds.

Come celebrate with us!

Be sure to stop by our booth at AHIMA’s 87th Convention and Exhibit in New Orleans September 26-30, 2015 to celebrate our anniversary as well as the industry’s monumental transition to ICD-10. We’d love to reconnect with colleagues and meet many new ones as well. Come and share your story with us.

About In Record Time, Inc.

In Record Time, Inc. is a national consulting firm on the leading edge of Health Information Management protocols. We are proud to offer the full spectrum of HIM services. In Record Time offers expertise in all aspects of Health Information Management. Our team is comprised of skilled professionals including Directors of Health Information Management, Credentialed Coders, Cancer Registry Specialists, and an in-house Information Technologies staff. Our customer service and attention to detail is unsurpassed in the industry. In Record Time offers innovative, cost-effective remote HIM solutions for any size facility. For more information, visit http://www.inrecordtime.net/.

 By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

 Over the last decade, it has become more and more challenging to maintain coding efficiency. In addition to ensuring accurate code assignment, today’s coders must:

 Review documentation more thoroughly to mitigate auditor scrutiny

  • Know where and how to find information in the electronic health record

  • Be able to sift through copy and paste documentation

  • Ensure clinical validation

  • Query when documentation is unclear or ambiguous

     

    Some coders also perform abstraction, physician education, and more. In the midst of all of this, coders must turn their attention toward ICD-10 to ensure accuracy and specificity.

     

    As HIM directors and managers continue to prepare for ICD-10, it’s important to re-evaluate coding workflow and processes to ensure maximum efficiency. Current inefficiencies will become magnified in ICD-10, leading to a domino effect of delayed reimbursement and denials that no organization can afford. Following are some tips that managers can use to streamline coding efficiency today and heading into ICD-10.

     

    Tip #1: Provide comprehensive ICD-10 coder training. This truly cannot be emphasized enough. Coder training will be one of the most significant determinants of efficiency and productivity in ICD-10. Even if coders have already received formal training, ensure that they continue to receive refresher training as well as adequate time to practice dual coding between now and October 1, 2015.

     

    Tip #2: Ensure sufficient coverage. Many organizations are hiring additional coders or contracting with outsource vendors to provide coverage before, during, and after the transition to ICD-10. Managers may also want to consider expanding the five-day workweek to include evenings and/or weekends. Coding backlogs can easily occur when coders only work Monday through Friday. This backlog can increase exponentially when ICD-10 takes effect. To ensure a smooth cash flow, consider a rotating schedule for overtime work or hiring an outsource vendor to handle cases after normal business hours and on weekends. Even focusing on ER records only can make a big difference.

     

    Tip #3: Consider removing non-coding duties. Managers may be able to increase coder efficiency by allowing coders to focus solely on coding. Doing so would absolve them of responsibilities such as CDI, answering the telephone, abstracting, and answering questions from patients. Each organization must determine what—if any—responsibilities can be reassigned to other individuals.

     

    Tip #4: Ensure that coders know when to report symptom codes. Outpatient coders can become particularly bogged down when reporting signs and symptoms that have little clinical pertinence to the case and that don’t pertain at all to medical necessity. For example, coders may report nausea when the patient has acute cholecystitis. In the outpatient setting, coders must code to the highest degree of specificity documented; however, it’s not appropriate to code signs and symptoms that are related to the underlying diagnosis.

     

    Tip #5: Consider implementing computer-assisted coding (CAC). CAC can potentially be a game changer in terms of coding efficiency on the inpatient side. However, implementation of CAC is a long process that must include considerable oversight. CAC technology is only as effective as the documentation on which it’s based. Coders must continue to review and audit any codes that the CAC technology suggests.

     

    Tip #6: Hire an external vendor to perform a workflow assessment. Such an assessment includes looking at the progression of documentation and processes that occur beginning with the moment the patient enters the facility to the moment he or she is discharged.

     

    Tip #7: Take a close look at documentation. Coding efficiency and productivity are directly linked to the quality of physician documentation. If documentation is subpar, coders’ efficiency—and perhaps accuracy—will be compromised. Consider the following questions:

      

  • Do physicians document all possible CC and MCC conditions to reflect patient severity? If not, what CC and MCC conditions are typically lacking? Do physicians need additional education? How can the organization convey the importance of these conditions in terms of reimbursement as well as overall clinical care?

     

  • Can the organization capitalize on dictation when possible? Although there seems to be a general push toward online documentation in which physicians enter information into templates via the EHR, I’ve observed that physicians are more likely to provide rich clinical details when they are dictating. These details and observations are critical for coding purposes. If physicians enter information into templates, does it include all of the data necessary for coding? If not, can physicians rely on dictation in some instances? In an ideal world, physicians would have the option of dictating or using a template in real time depending on the clinical scenario. Some organizations have even begun to use scribes (i.e., medical students or nursing staff) who dictate the entire clinical experience. This works particularly well in the ED setting. The goal is to provide flexibility while maintaining clinical integrity within the documentation.

     

  • What is the quality of the discharge summary? The discharge summary is particularly important for coding purposes, as some conditions cannot be coded unless a physician validates them in the discharge summary. However, the quality of a discharge summary often varies by organization or even individual physician. Coders are more efficient when the discharge summary is accurate and detailed, providing a thorough glimpse into the entirety of the patient’s stay.

     

    Tip #8: Implement an electronic document management system (EDMS). Organizations that continue to scan records partially or entirely face many challenges in terms of coding efficiencies. Coders often struggle with simply finding the information they need for coding purposes. I’m aware of at least one hospital in which coders must scan through 8-10 pages of information before they find clinical data. An EDMS can help coders index and retrieve information more easily. This will be incredibly valuable heading into ICD-10.

     

    Tip #9: Talk to the coders. By talking openly with coding staff members, managers can identify frustrations and other concerns that could take a toll on productivity. Do coders feel supported by the larger administration? Do technology challenges slow coders down? Can coders rely on clear and updated policies and procedures? Remember that happy coders are efficient coders.

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