Evaluating Claim Production Data $($Level $5$Evaluating$)$

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 Macomb 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. Macomb 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.

Create a graphic display that summarizes the coding unit$$s performance in relation to their standard. You will need to calculate the clean claim percentage for each edit as well as an overall percentage for the month and then quarter. $($ie: $($total claims$-$edit$)/$total claims x$100=\%$ of clean claims$)$

Prepare a summary statement about the coding unit$$s quarterly performance:

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.