Claim adjustment

As a leader and manager, the health informationadministrator is responsible for monitoring and evaluating theperformance of processes. This responsibility requires the manager todetermine key performance indicators to be included in the monitoringand evaluation process. You are the HIM director at Memorial Hospital. Youare a member of the revenue cycle department and are charged withmonitoring and evaluating key HIM RC processes that impact the stabilityand health of the facility’s revenue cycle. During the claims, production process claims arescrubbed and modified to ensure that a clean claim is submitted to thepayer. Memorial Hospital tracks claims through this process so thatinefficiencies in the RC can be addressed. Below are the claimsproduction data for

April

through June. The HIM coding unit’s cleanclaim metric standard is 9

5

percent. Prepare a summary statement of at least 300 wordsregarding the coding unit’s quarterly performance. Also, create agraphic display that summarizes the coding unit’s performance inrelation to their standard. Is the unit performing as expected, or isthere a need for a root cause analysis and process improvement? If thereis room for improvement, brainstorm some ways the coding manager couldeducate the staff.

Claim Production Quarterly Report—Memorial Hospital

Claim Issue Identified by Scrubber

Number of Claims Requiring Rework Prior to Submission

April

May

June

5,500 claims processed

6,200 claims processed

5,850 claims processed

Claim failed patient identifier edits

115

213

137

Claim failed provider identifier edits

12

5

21

Claim failed coding/modifier edits

220

496

351

Claim failed date of service edits

10

25

14

As a leader and manager, the health information administrator is responsible for monitoring and
evaluating the performance of processes. This responsibility requires the manager to determine
key performance indicators to be included in the monitoring and evaluation process.
You are the HIM director at Memorial Hospital. You are a member of the revenue
cycle department and are charged with monitoring and evaluating key HIM RC processes that
impact the stability and health of the facility’s revenue cycle.
During the claims, production process claims are scrubbed and modified to ensure that a clean
claim is submitted to the payer. Memorial Hospital tracks claims through this process so that
inefficiencies in the RC can be addressed. Below are the claims production data
for April through June. The HIM coding unit’s clean claim metric standard is 95 percent.
Prepare a summary statement of at least 300 words regarding the coding unit’s quarterly
performance. Also, create a graphic display that summarizes the coding unit’s performance in
relation to their standard. Is the unit performing as expected, or is there a need for a root cause
analysis and process improvement? If there is room for improvement, brainstorm some ways the
coding manager could educate the staff.
Claim Production Quarterly Report—Memorial Hospital
Number of Claims Requiring Rework Prior to Submission
April
May
June
5,500 claims
processed
6,200 claims
processed
5,850 claims
processed
Claim failed patient identifier edits
115
213
137
Claim failed provider identifier edits
12
5
21
Claim failed coding/modifier edits
220
496
351
Claim failed date of service edits
10
25
14
Claim Issue Identified by Scrubber