Credibility in Times of Crisis

Health information management (HIM) as a profession has morphed into a variety of roles, functions, and responsibilities within and outside of the traditional HIM department. While many healthcare stakeholders still associate HIM with medical record stewardship, it is clear that tracking, organizing, and disseminating rich data—as well as bridging the gap between what information is needed versus what information may be requested—is still central to HIM professionals’ expertise.

The COVID-19 pandemic presents numerous challenges and opportunities for HIM professionals, who are generally solutionists by nature. Thus, where there are opportunities, they can credibly contribute.

This global crisis calls for creativity. While the circumstances of the pandemic are unfortunate, resourceful HIM professionals have identified more efficient ways of doing business and have turned a spotlight on their profession’s contributions to the healthcare ecosystem in the process, including:

Privacy and Security. There is a stigma associated with COVID-19. Because any contagious disease can cause panic and fear, healthcare professionals need to be very careful with any disclosures regarding potentially affected individuals. At the same time, the healthcare community is also aware of the need to balance patient privacy with the need to track the spread of a rapidly spreading disease. There have been ongoing discussions regarding COVID-19 surveillance, which involves tracking the movements of positive individuals; monitoring the proximity of others to positive individuals; and studying the activity of residents’ comings and goings in areas where stay-at-home mandates are in place.¹ All of these raise privacy issues in the eyes of many Americans and must be weighed against public health risk.

Code Assignment. That HIM professionals are considered the experts in code assignment for ICD-10-CM, ICD-10-PCS, and CPT coding is no surprise. However, the pandemic has triggered the Centers for Disease Control and Prevention (CDC) to exercise its right to activate an ICD-10-CM code for COVID-19 with an effective date of April 1, 2020. Because it is well known that these new codes are typically effective October 1 of each year, the beginning of the government’s fiscal year, this may present difficulties in accurate coding of COVID-19 cases. The new code, U07.1, is not retroactive so initial cases had a different code assigned, which might further complicate future inquiries for retrospective case studies. This is also an ideal time to ensure that social determinants of health are documented and coded.

Additionally, new CPT and HCPCS codes were made available for COVID-19 lab tests. These codes are retrospective in nature, which may prove to be yet another layer of complexity for future data reconciliation. The first, U0001, is for SARS-CoV-2 diagnostic testing for CDC. The next code, U0002, was released to allow for expanded laboratory billing for non-CDC lab tests.

Clinical Documentation Integrity. CDI professionals are tasked with reviewing specific populations of patients. For example, OB-GYN, ophthalmology, or plastic surgery cases may not be prioritized for review, depending on size and maturity of the CDI program. However, during a pandemic, it may be prudent to have CDI review 100 percent of COVID-19 admissions to ensure the most complete documentation, reflecting the most accurate severity of illness and risk of mortality is represented upon discharge. While this high level of quality is always necessary for every patient, it is times like these that remind healthcare professionals that coding was put in place initially for tracking and trending of diseases. The retrospective studies, research, and requests for information for these patients will be accessed and dissected for many years to come. If there are any other patient characteristics, socioeconomic circumstances, or other risk factors that may predispose patients to respond to the virus differently, it is incumbent upon healthcare professionals at every level to ensure that they are documented, captured, and reported with the highest level of integrity.

Data Disparities. There are challenges with understanding how to use the various code sets outside of the coding department. For example, when the finance department tries to gain an accurate count for the number of COVID-19 patients seen at their organization, if there is no collaboration with HIM, there could be problems. Pulling data using the wrong code or an incomplete code will not yield the results expected. Trying to capture a patient count by counting the number of positive test results or using the number of tests ordered may or may not result in the information needed. For example, if a patient tested positive in the community was admitted from another healthcare facility. Discussions with HIM and coding leaders to find out the intent and to assist with reconciliation of the data is paramount.

Workforce Impacts

COVID-19 affects HIM professionals in other ways that are more personal and career-oriented, such as:

Work From Home Policies. HIM leads the way in sharing best practices with other departments on effective telecommuting. Because social/physical distancing is one of the most effective ways to slow the spread of COVD-19, many employers were immediately tasked with mobilizing their employees to work from home. Generally, this is only allowed after extensive pilot periods—where groups that are working from home report their progress to taskforces set up to study it. Implementing a policy can take years. However, because this is a prevalent practice in HIM, particularly for coding professionals, they can share agreements, policies, and equipment checklists available to other departments.

Still, another factor to consider is staying connected via remote work. This often means the increased use of videoconferencing, such as WebEx and Zoom. In some cases, HIM has finessed this skill. In other cases, this is a new opportunity for providing guidance. One Midwestern medical facility shared that before COVID-19, they used approximately 300,000 minutes of web-based conferencing time per month, but post-COVID-19, utilization was tracked at over 1.4 million minutes. Most importantly, not all platforms are equal. Be sure to check into the security of the platform, especially if protected health information (PHI) will be discussed.

Employment Impact. The US response to the virus has caused many unforeseen consequences, such as reduced hours, furloughs, and job losses for many coders—particularly for outpatient coders. This notion is contrary to the previous predictions of the ever-increasing volumes of outpatient services. While the inpatient volumes were also severely reduced, due to the canceling of many outpatient visits and elective surgeries, the inventory of accounts available for coding diminished across the board. Also, managers of HIM staff whose jobs may be difficult to perform from home may have had difficult choices to make.

Although the vast majority of HIM work can be performed remotely thanks to electronic health records (EHRs), not all documentation in health is computer generated. There are often still paper documents that may need to be retrieved from the units, floors, and departments in order to be scanned. HIM professionals that perform these and other vital roles face a difficult choice between staying employed with fear of COVID-19 exposure or minimizing risk by staying at home. Many HIM leaders combat this loss of employment by focusing on special projects for these employees. Additionally, some organizations have redeployed some of the professionals to work at temporary temperature screening locations to ensure the clinical workers, patients, and visitors are not symptomatic for COVID-19 prior to entering the building.

Unique HIM Needs During the Pandemic

Today’s healthcare environment is especially fraught with new federal and state regulations—some that are temporary that deal directly with the pandemic, and some that are not. HIM professionals are still navigating the landscape of waivers, stimulus funding, and loosened regulatory requirements aimed at decreasing administrative burdens.

Regulatory Environment. The Coronavirus Aid, Relief, and Economic Security (CARES) Act was passed by Congress on March 27. It provides $100 billion in stimulus funding to hospitals caring for COVID-19 patients. The government also issued waivers, which providers can apply for, that continue to allow flexibility with regard to reimbursement and care for uninsured individuals and other emergency benefits.2,3

Chart Completion/Deficiencies. The crisis has allowed some hospitals to accept help from physicians from other countries who are not as familiar with American documentation standards. At one organization, HIM and coding professionals stepped in to coach an Australian cardiovascular surgeon through the documentation standards required for accurate code assignment.

Skilled Nursing Facility Transfers. Skilled nursing facilities (SNFs) have been particularly impacted by transfers of COVID-19 patients. Initially, there were discussions about SNFs not being available to accept some of these patients that met criteria for discharge from acute care status. While subsequent interim guidance for COVID-19 patients in SNFs issued by the CDC may have decreased the frequency of this scenario, HIM is greatly impacted. When patients cannot be discharged in a timely fashion and there is no interim coding or review of these records, code assignment post discharge can be daunting.4

Telehealth. This time of social distancing and stay-at-home orders has been an ideal testing ground for expanding the capabilities of telehealth. Many regulations surrounding telehealth have also been relaxed—primarily, the HIPAA requirement for secure devices. This means the patient can connect using the device or platform of their choice. But pre-existing HIM challenges around telehealth remain. There is little interoperability between telehealth platforms and EHRs, which creates difficulties sharing secure and compliant documentation between providers. Furthermore, reimbursement varies, if it is covered at all by private insurance.

Because many outpatient, clinic, office, or other ambulatory visits were canceled, telehealth has its time to shine. Still, “while it is clear its use has skyrocketed in recent weeks — it went from comprising virtually no visits as late as March 8 to 30% as of April 12—it is not even close to completely replacing in-person encounters. In-person encounters were down 67% as of April 12 (versus a 54% decline in all visits in total),” according to a Healthcare Dive article. Ultimately, telemedicine encounters replaced less than 20 percent of the pre-COVID-19 volume of patient visits. Some companies, such as Teladoc, have seen patient visits more than double compared to early March.5

Teamwork. Collaboration during time of crisis is a necessity. Now is the time for HIM professionals to offer their input for solutions. Teaming with departments such as revenue cycle, finance, IT, informatics, legal, and compliance is required to stay abreast of the rapid regulatory changes and internal directives. Certainly, HIM plays an important role in data reconciliation and integrity to ensure accuracy of documentation and to ensure appropriate reimbursement is received for the care of COVID-19 patients. When inventory is low, HIM professionals may be able to help in other areas such as screening stations, maximize opportunities for education and training, and take the lead on other special projects.

Leadership. COVID-19 presents many opportunities for HIM to take the lead. Perhaps new policies are needed to accommodate many of the regulatory changes. There may be a need to craft a disaster documentation requirements policy. Also, as leaders, staying positive for your team, your family, and yourself is critical. Check on your staff to ensure their well-being. The pandemic causes some concerns related to isolation for some even while the solitude is embraced by others. Avoiding crowded places can affect the psyche of some. For others, staying in close proximity with children and spouses is new territory. Make sure to share resources such as employee assistance programs.

On the Horizon

Although recovery plans are already being initiated, agility is still key. In some states, healthcare facilities are planning to begin seeing some surgical patients—especially those not requiring an overnight stay. How to prioritize and reschedule the massive amounts of patients may be daunting. Surgeries are starting to ramp up again. However, the fear of coming to a healthcare facility potentially housing COVID-19 patients may cause hesitation. Unemployment also leads to loss of health insurance for many.

Health information professionals have the experience and creativity to navigate a new and different healthcare landscape. Their expertise with data integrity and compliant documentation are skills that will continue to be necessary to combat COVID-19. Unusual circumstances call for unusual solutions. With practices such as social distancing and work from home mandates, it is entirely possible that a new norm is forming. Remaining calm during chaos and finding alternative approaches to performance while motivating others to do the same will help prepare for what is on the horizon.

Author’s Note: Join me in the AHIMA Engage community to keep the discussion going. Sharing best practices among HIM professionals is a part of what makes our community thrive.

Notes

Halpern, Sue. “Can We Track COVID-19 and Protect Privacy at the Same Time?” The New Yorker, April 27, 2020. https://www.newyorker.com/tech/annals-of-technology/can-we-track-covid-19-and-protect-privacy-at-the-same-time.

LaPointe, Jacqueline. “Key Waivers, Regulatory Flexibility for Providers During COVID-19.” Rev Cycle Intelligence, March 17, 2020. https://revcycleintelligence.com/news/key-waivers-regulatory-flexibility-for-providers-during-covid-19.

Health Resources and Services Administration. COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured. https://www.hrsa.gov/CovidUninsuredClaim.

Centers for Disease Control and Prevention. Nursing Homes & Long-Term Care Facilities. May 19, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html.

Shinkman, Rob. “Outpatient visits plunged in second half of March, Commonwealth Fund says.” Healthcare Dive. April 23, 2020. https://www.healthcaredive.com/news/outpatient-visits-plunged-in-second-half-of-march-commonwealth-fund-says/576699/.

References

Centers for Medicare and Medicaid Services. Coverage and Payment Related to COVID-19 Medicare. https://www.cms.gov/files/document/03052020-medicare-covid-19-fact-sheet.pdf.

Dwan Thomas Flowers (HIMprofexcel@bellsouth.net) is an independent healthcare consultant currently serving as interim administrative director of medical information management for Maxim Healthcare. She also serves as a director for the AHIMA Foundation Board.

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Continuing Education Quiz

Review quiz questions and take the quiz based on this article, available online.

• Quiz ID: Q2029107
• Expiration Date: July 1, 2021
• HIM Domain Area: Organizational Management and Leadership

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