“The world, to me, doesn’t revolve around acute care, our
goal is keeping people out of hospitals. It’s not just a trend. It’s
where things are going. Care is happening in the community,”
says Michelle Dougherty, MA, RHIA, CHP, senior health informatics research scientist, digital health policy and standards,
at RTI International.
Dougherty says there’s tremendous opportunity for HIM professionals in long-term and post-acute care (LTPAC) settings,
especially as telemedicine and telemonitoring tools grow in
use and as the population ages. “We are well positioned, in
our expertise, to really advance current LTPAC practices, and
support the direction we’re going in with interoperable data,”
This article examines how HIM is handled in several non-acute care settings, and the challenges and successes HIM
professionals have seen in these areas when it comes to documentation, reimbursement, technology changes, privacy, security, and interoperability.
HIM in Long-Term Care Hospitals
HIM professionals working in long-term acute care hospitals
(LTACs) have their work cut out for them. The typical length
of stay in an LTAC combined with the acuity of the patients
means that a patient’s chart can run hundreds of pages in a
very short amount of time. Patients being treated in this setting can be on ventilators, have spinal cord injuries, traumatic
brain injuries, and other complex conditions.
Kathy DeVault, MSL, RHIA, CCS, CCS-P, FAHIMA, manager
of HIM consulting at UASI, is an HIM consultant who works in
a variety of post-acute settings. In her experience, coding in
LTACs is usually done by coders who might be “home grown”
or credentialed. Due to the acuity of the patients and the documentation needed to reflect their care, however, it’s increasingly important that such facilities hire credentialed coders.
“I think the risk is significant in not using designated cod-
ers to do the work because of the understanding of ICD- 10 and
understanding the anatomy and physiology and pathophysi-
ology of what’s going on with the patient,” DeVault says. “Be-
ing able to distinguish between a symptom and a condition [is
important for coding].”
For example, a clinician might mention “weakness” multiple
times while documenting in a chart. A coder needs to under-
stand that they should not use a code for weakness because it’s
associated with paraplegia.
“And there’s a coding guideline that tells us that. But in some
cases the coding of the weakness is necessary to tell the whole
story about what’s happened to that patient,” DeVault says.
Like just about every care setting, interoperability is a struggle in LTACs. Patients are admitted to these facilities from hospitals and intensive care units, and are sometimes discharged
to home health or skilled nursing facilities. Keeping a longitudinal record is challenging.
“What’s really key with these kind of patients is the longi-
tudinal ability and record collection. Can we look at ‘Kathy
DeVault’ and her illness in the spectrum from when she had
the accident to her long-term care? It’s not a challenge for
these settings, but it’s a challenge for interoperability overall,”
In long-term care hospitals, skilled nursing facilities, and
other outpatient settings, medical records are often a hybrid
of electronic and paper, which can increase the level of risk,
especially with written prescriptions. This is partly due to
post-acute facilities being left out of the meaningful use program when it was launched, which offered financial incentives to those who implemented and properly used EHRs. This
has caused disruption in home health and post-acute settings
when trying to transfer patient’s medical records. Often, there
are completely separate medical records between hospitals
and long-term care facilities—even when they are owned by
the same parent company.
HIM in Hospice
By its nature, hospice has a lot in common with home health
and skilled nursing settings; hospice care can be provided in
an individual’s home or in designated wings of hospitals or
skilled nursing facilities. As a result, hospice providers inherit
health IT applications originally designed for home health or
skilled nursing facilities, which are then adapted to meet hospice needs. But right-sizing this software for hospice doesn’t
always work, according to Shawna Zastoupil, RHIT, hospice
coding manager for the consulting group Corridor.
For example, in one EHR system that’s been adapted to hospice, if a coder is in the process of reviewing a chart after a patient’s been admitted, then the record can’t process physician
orders. This can be a substantial hardship for the patient getting palliative care.
“So we have a sick person who’s in hospice and a coder doing
their due diligence trying to get through referral documentation, and that can take up to 24 hours. The orders for pain meds
cannot be processed [until] that coder is done with the EMR
[electronic medical record],” Zastoupil says.
In recent years, the Centers for Medicare and Medicaid Services (CMS) has changed coding guidelines for hospice, presenting challenges for hospice coders, Zastoupil says. Until a
new regulation that came out in 2013, coders only had to use
one ICD- 10 code per claim.
Under new CMS guidelines, in terms of a principal diagnosis, “when the provider has established, or confirmed, a related definitive diagnosis, codes listed under the classification
of Symptoms, Signs, and Ill-defined Conditions are not to be
used as principal diagnoses. Hospice providers may not report
diagnosis codes that cannot be used as the principal diagnosis
according to ICD-9-CM/ICD-10-CM Coding Guidelines and
that require further compliance with various ICD-9-CM/ICD-
10-CM coding conventions, such as those that have principal
diagnosis code sequencing or etiology/manifestation guidelines.” 1
This change increased the profile of certified coding professionals in hospice. Nurses used to do the majority of the coding, but with the new guidelines and quality measure reporting now required of hospices, there’s a growing demand for