1. Evaluating Claim Production Data (Level 5Evaluating)

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 is the claims production data for April through June. The HIM coding unit's clean claim metric standard is 95 percent.

Prepare summary statement about the coding unit's quarterly performance. Create graphic display that summarizes the coding unit's performance in relation to their standard. Is the unit performing as expected, or is there 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 ReportMemorial 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