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In Record Time, Inc. Celebrates 20 Years of Service in the HIM Industry

In Record Time, Inc. is pleased to announce its 20th anniversary partnering with countless organizations to provide coding, abstracting, auditing, oncology data management, ICD-10 training, revenue cycle management, and HIM clerical services. The company is honored to be able to recognize this milestone, and it celebrates the clients that have made the company’s success possible. 


In Record Time established its humble roots in 1995 during a time when organizations were just starting to transition their medical record departments to health information management departments. In a paper-based world, In Record Time assisted clients with assembly and analysis of paper records as well as loose filing.


As organizations transitioned to electronic health records, In Record Time responded by providing scanning functions and top notch coding services via a secure remote platform. As third-party auditors increased their volume of audits and scrutiny of documentation, In Record Time responded by auditing clients with that same level of detail and also implementing an internal QA process to ensure consistency and accuracy. As HIM departments shifted their attention to ICD-10, In Record Time responded by providing back-up coding support, dual coding services, and thorough ICD-10 training for its own credentialed coding staff. 


In Record Time knows that the world of HIM is in constant flux and that clients need a partner that can adapt to change quickly while providing cost-effective services. “I think HIM is a very dynamic industry. You can always expect the unexpected. We’ve had the foresight to evolve and change with that,” says Renee Klarberg, MPS, RHIA, who originally founded the company after having worked in various large acute care hospitals for many years.


What began as a small enterprise, In Record Time has grown exponentially, and its dynamic team boasts highly-experienced and credentialed coding and compliance personnel, certified tumor registrar professionals, and seasoned HIM operations and information technology staff, all of whom are based in the United States.


Although In Record Time has evolved commensurate with technology, the customer service principles on which the company was founded remain the same. Since its inception, the company has provided personalized and high-quality services based on a foundation of open and honest communication. Each client is unique, and In Record Time strives to provide services that can easily be adapted to changes in staffing and coding volumes. “We’re very old fashioned in a sense. My biggest rule is that you always have to respond to your client within 24 hours,” says Douglas L. Klarberg, JD, vice president, who followed in Renee’s footsteps when he joined the family business in 2008. “We pride ourselves in building solid relationships with our clients, and we take these relationships very seriously. Our number one priority is to work hard and provide the highest quality services to our clients.”


Looking ahead to ICD-10
In Record Time understands the workflow and staffing challenges inherent in ICD-10. Using a proprietary tool, In Record Time can accommodate workflow fluctuations associated with ICD-10 and provide ample coding support during a time when productivity is expected to decrease significantly. 


“Our expertise in being able to help clients gear up quickly for very large projects is an asset when it comes to ICD-10,” he says. “We also have an extensive network of coders with whom we’ve worked over the years. We’re constantly sourcing and testing candidates as well.”  


In Record Time also knows that there continues to be many unknowns with ICD-10. How will it truly affect coding productivity in a live environment? Will the volume of queries increase? What will happen if denials are on the rise? “Just as we’ve adapted to change in the past, our approach to ICD-10 will be no different. We’ll work right beside our clients to ensure their success. It’s a team effort, and we’re there to provide all of the support that our clients need,” he adds.


Come celebrate with us!
Be sure to stop by our booth at AHIMA’s 87th Convention and Exhibit in New Orleans September 26-30, 2015 to celebrate our anniversary as well as the industry’s monumental transition to ICD-10. We’d love to reconnect with colleagues and meet many new ones as well. Come and share your story with us.



About In Record Time, Inc.
In Record Time, Inc. is a national consulting firm on the leading edge of Health Information Management protocols. We are proud to offer the full spectrum of HIM services. In Record Time offers expertise in all aspects of Health Information Management. Our team is comprised of skilled professionals including Directors of Health Information Management, Credentialed Coders, Cancer Registry Specialists, and an in-house Information Technologies staff. Our customer service and attention to detail is unsurpassed in the industry. In Record Time offers innovative, cost-effective remote HIM solutions for any size facility. For more information, visit http://www.inrecordtime.net/.

9 tips to streamline coder productivity heading into ICD-10

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Over the last decade, it has become more and more challenging to maintain coding efficiency. In addition to ensuring accurate code assignment, today’s coders must:

·         Review documentation more thoroughly to mitigate auditor scrutiny

·         Know where and how to find information in the electronic health record

·         Be able to sift through copy and paste documentation

·         Ensure clinical validation

·         Query when documentation is unclear or ambiguous

Some coders also perform abstraction, physician education, and more. In the midst of all of this, coders must turn their attention toward ICD-10 to ensure accuracy and specificity.

As HIM directors and managers continue to prepare for ICD-10, it’s important to re-evaluate coding workflow and processes to ensure maximum efficiency. Current inefficiencies will become magnified in ICD-10, leading to a domino effect of delayed reimbursement and denials that no organization can afford. Following are some tips that managers can use to streamline coding efficiency today and heading into ICD-10.

Tip #1: Provide comprehensive ICD-10 coder training. This truly cannot be emphasized enough. Coder training will be one of the most significant determinants of efficiency and productivity in ICD-10. Even if coders have already received formal training, ensure that they continue to receive refresher training as well as adequate time to practice dual coding between now and October 1, 2015.

Tip #2: Ensure sufficient coverage. Many organizations are hiring additional coders or contracting with outsource vendors to provide coverage before, during, and after the transition to ICD-10. Managers may also want to consider expanding the five-day workweek to include evenings and/or weekends. Coding backlogs can easily occur when coders only work Monday through Friday. This backlog can increase exponentially when ICD-10 takes effect. To ensure a smooth cash flow, consider a rotating schedule for overtime work or hiring an outsource vendor to handle cases after normal business hours and on weekends. Even focusing on ER records only can make a big difference.

Tip #3: Consider removing non-coding duties. Managers may be able to increase coder efficiency by allowing coders to focus solely on coding. Doing so would absolve them of responsibilities such as CDI, answering the telephone, abstracting, and answering questions from patients. Each organization must determine what—if any—responsibilities can be reassigned to other individuals.

Tip #4: Ensure that coders know when to report symptom codes. Outpatient coders can become particularly bogged down when reporting signs and symptoms that have little clinical pertinence to the case and that don’t pertain at all to medical necessity. For example, coders may report nausea when the patient has acute cholecystitis. In the outpatient setting, coders must code to the highest degree of specificity documented; however, it’s not appropriate to code signs and symptoms that are related to the underlying diagnosis.

Tip #5: Consider implementing computer-assisted coding (CAC). CAC can potentially be a game changer in terms of coding efficiency on the inpatient side. However, implementation of CAC is a long process that must include considerable oversight. CAC technology is only as effective as the documentation on which it’s based. Coders must continue to review and audit any codes that the CAC technology suggests.

Tip #6: Hire an external vendor to perform a workflow assessment. Such an assessment includes looking at the progression of documentation and processes that occur beginning with the moment the patient enters the facility to the moment he or she is discharged.

Tip #7: Take a close look at documentation. Coding efficiency and productivity are directly linked to the quality of physician documentation. If documentation is subpar, coders’ efficiency—and perhaps accuracy—will be compromised. Consider the following questions:

·         Do physicians document all possible CC and MCC conditions to reflect patient severity? If not, what CC and MCC conditions are typically lacking? Do physicians need additional education? How can the organization convey the importance of these conditions in terms of reimbursement as well as overall clinical care?

·         Can the organization capitalize on dictation when possible? Although there seems to be a general push toward online documentation in which physicians enter information into templates via the EHR, I’ve observed that physicians are more likely to provide rich clinical details when they are dictating. These details and observations are critical for coding purposes. If physicians enter information into templates, does it include all of the data necessary for coding? If not, can physicians rely on dictation in some instances? In an ideal world, physicians would have the option of dictating or using a template in real time depending on the clinical scenario. Some organizations have even begun to use scribes (i.e., medical students or nursing staff) who dictate the entire clinical experience. This works particularly well in the ED setting. The goal is to provide flexibility while maintaining clinical integrity within the documentation.

·         What is the quality of the discharge summary? The discharge summary is particularly important for coding purposes, as some conditions cannot be coded unless a physician validates them in the discharge summary. However, the quality of a discharge summary often varies by organization or even individual physician. Coders are more efficient when the discharge summary is accurate and detailed, providing a thorough glimpse into the entirety of the patient’s stay.

Tip #8: Implement an electronic document management system (EDMS). Organizations that continue to scan records partially or entirely face many challenges in terms of coding efficiencies. Coders often struggle with simply finding the information they need for coding purposes. I’m aware of at least one hospital in which coders must scan through 8-10 pages of information before they find clinical data. An EDMS can help coders index and retrieve information more easily. This will be incredibly valuable heading into ICD-10.

Tip #9: Talk to the coders. By talking openly with coding staff members, managers can identify frustrations and other concerns that could take a toll on productivity. Do coders feel supported by the larger administration? Do technology challenges slow coders down? Can coders rely on clear and updated policies and procedures? Remember that happy coders are efficient coders.

Make ICD-10-PCS training a priority in the New Year

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Coders are among the busiest employees in any hospital nationwide. However, they must make time to practice using ICD-10 even despite strict productivity requirements. In particular, practicing ICD-10-PCS will be critical as the industry heads into 2015. 

ICD-10-PCS is far more complex than the ICD-9-CM procedure coding system to which today’s inpatient coders are accustomed. In PCS, coders must be able to complete a seven digit alphanumeric formula. If they’re unable to assign even one character in the formula, they’ll be unable to assign the entire code. 

Experts agree that without critical details in the documentation, coders may default to non-specific codes. This is certainly not the intent of the more specific PCS coding system. It’s in coders’ best interests to practice using PCS as much as possible between now and October 1, 2015.

Where should coders focus their ICD-10-PCS training efforts? One of the most difficult aspects of ICD-10-PCS may be assignment of the root operation. For this reason, coders may want to devote significant time in this area. Identifying an improper root operation can lead coders down a completely incorrect path to code assignment. Incorrect code assignment ultimately jeopardizes both reimbursement and data integrity.

Coders should also spend the majority of their time practicing more complex cases, such as CABG procedures, OB/GYN procedures, orthopedic surgeries, and neurosurgical cases. These procedures are the ones that will likely cause bottlenecks in terms of productivity. Some of these procedures may even require more than one PCS code to fully capture the entire operation the physician performs. 

Another approach is to focus on high-volume procedures; however, keep in mind that these procedures may not be the most complex and therefore time-consuming.

Once coders have mastered root operation definitions, focus on whether coders can translate clinical terminology to a specific PCS operation. Physicians are not expected to make this translation. The 2015 ICD-10-PCS Official Guidelines for Coding and Reporting state the following:

 It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear.

How can coders work with medical staff to practice ICD-10-PCS? Ask medical staff members to identify the top 10 most complex procedures that they perform. Also inquire whether physicians would be willing to walk coders through the steps they take during each of these procedures. This can help coders visualize the procedure when coding.

Physicians should have already begun to document the additional details necessary for ICD-10-PCS, such as anatomical specificity and laterality. When physicians document these details, not only are they practicing good habits, but they’re also making records more helpful for coders who will use de-identified versions for practice purposes. If these details are missing from the record, coders have no choice but to assign an unspecified code.

Why is it important to audit for quality? Even when coders practice ICD-10-PCS on a daily basis, they’re still bound to make mistakes. Quality monitoring is critical, both now and once the new coding system takes effect. As coders practice using PCS, ensure that a manager verifies their work. When questions or discrepancies arise, address these topics during coding staff meetings. Develop internal coding guidelines to identify how coders will tackle certain procedures in lieu of updated Coding Clinic references.

How can organizations make coder training in general a priority? Unfortunately, training and education budgets are often among the first to be reduced or cut entirely when organizations seek to reduce operating costs. Coding managers and HIM directors must work with hospital executives to explain the importance of ICD-10 and the role it plays in the overall financial viability for the organization. As was the case with the transition to DRGs in the early 1980s—as well as MS-DRGs in 2007—organizations likely won’t realize the true impact of ICD-10 until after implementation. We shouldn’t let history repeat itself. Investing in up-front coder training will mitigate the impact of the new coding system as much as possible.

Avoid these mistakes when conducting internal coding audits

By Mike Evans, RHIA, CCS, vice president of coding and compliance at In Record Time, Inc.

Internal coding audits have always been important. However, as third-party auditors continue to scrutinize documentation and coding practices, it’s more important than ever to ensure that these audits occur regularly and that they’re effective. All too often, internal auditors overlook critical aspects of the audit, resulting in skewed data that may not paint a clear picture of trends and patterns. Even when conducted properly, audits may not yield results that are truly useful to the organization.

Following are some of the most common mistakes that internal coding managers and/or HIM directors make when conducting internal coding audits.

1. Audits are too narrow. Internal managers sometimes approach an audit with an agenda to increase CC or MCC capture. When organizations narrow their focus in this way, they may miss out on other problems within the documentation or coding. Instead, organizations should focus audits on documentation integrity—not simply identifying missing elements that would have increased reimbursement. Ideally, audits should ensure the following:

·     Multiple CC and MCC capture, when appropriate. Capturing only one single CC or MCC may not be sufficient in terms of ensuring a correct severity of illness (SOI) or risk of mortality (ROM). SOI and ROM both affect the observed vs. expected death rate—an important indicator of the quality of care provided.

·     Correct POA indicator assignment. This plays an important role in patient safety indicator (PSI) scores. An inflated POA indicator rate could inflate the PSI rate as well.

·     Compliant complication reporting. Physicians are hesitant to label complications as such; however, organizations need to encourage physicians to document complications when they occur. Reiterate to physicians that complications that occur intra-operatively are generally not the fault of the physician, but rather they’re due to a problem with the patient’s own health circumstances.

2. Audits don’t look beyond the organization’s own walls. One of the biggest mistakes that organizations make is not looking at how their data compares with other facilities in the state, region, or nationwide. Knowing how your organization compares with its peers is important because patients have access to this data that is reported on an aggregate level to various state health agencies. Sites such as Physician Compare and Hospital Compare make it very easy for consumers to shop around for the best quality care. Organizations need to know how they stack up against other facilities so they can take steps to improve data quality and public perception.

Knowing how the organization compares with others is also important in terms of gauging vulnerability for external audits. The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a helpful resource that provides hospital-specific data statistics for improper payment targets. Organizations can use PEPPER to compare their data other hospitals or facilities in the state, specific Medicare Administrative Contractor (MAC) jurisdiction and the nation.

3. Auditors don’t look for the story behind the numbers. Internal auditors may not look for the root cause of audit results. Instead, they must simply assume that the results are based on incorrect coding. However, the trigger may be something process-related and/or entirely unrelated to coding. For example, if the organization’s procedure is to require coders to code without the discharge summary, this might affect a coder’s ability to capture the principal diagnosis correctly. Consider a transient ischemic attack (TIA). When a physician documents both a TIA and a cardiovascular accident (CVA) throughout the record—but doesn’t rule out the CVA until the discharge summary—how can the coder truly know what proper principal diagnosis to report?

Another example relates to septicemia vs. urinary tract infection (UTI). Are coders required to query when the record is unclear? Are they given sufficient time to do so? If not, unclear documentation could lead to an unusually high rate of septicemia that could appear quite alarming during an audit.

Other root causes could relate to insufficient physician documentation, EHR glitches, etc.

4. Auditors don’t use updated resources. It’s a full-time job to keep up with ever-changing audit targets and requirements. However, using outdated resources and references can provide skewed audit results. Be sure to use updated coding guidelines and updated insurer policies. The Recovery Auditor FY2013 Report to Congress and FY 2015 OIG Work Plan are also good references in terms of structuring an audit and keeping updated on the latest targets.

5. No follow-up education is provided. After the conclusion of an internal audit, provide audit results to coders, physician advisors, and CDI specialists. Include a physician advisor when providing education to physicians, as they generally respond more positively when receiving information from a peer.

6. Organizations don’t perform follow-up audits. Perform an audit six months after concluding the original audit. This ensures the efficacy of any steps taken to rectify problems identified during the first audit.

How an external vendor can help

External coding vendors provide an unbiased look at an organization’s data. These auditors don’t have an agenda, and they also have no connection to the data. They often provide the impartial analysis that organizations need.

In addition, external vendors can perform the type of in-depth data analysis necessary to compare an organization’s performance (i.e., its DRG and APC mix) with similar facilities on a city, state, regional, or national level. Many external auditors work with clients nationwide, meaning they bring a wealth of knowledge and experience to the table. Organizations benefit from this bird’s-eye view of what’s going on in the industry in terms of third-party auditor trends.

What May Be The Oldest Written Medical Records In Existence...

The earliest written records of Chinese medicine date back about 5000 years, and include the Huang-Di Nei-Jing, possibly the oldest medical text in the world. These records had great significance for the development of traditional Chinese medicine (TCM), and even for Western medicine. 

© Copyright 2013 Leslie Cohen, All rights Reserved. Written For: Decoded Past

This manuscript, found in a Han era tomb, gives prescriptions for 52 kinds of disease remedies. Image courtesy of Professor Ying Li, Shanghai Institute of Materia Medica, Chinese Academy of Science, Shanghai, China.

Chinese Medicine in the Archaeological Record  
Archaeologists have found some of the best information about the early use of Chinese medicine at grave sites. For example, two graves from the Han Dynasty (c. 202 BCE to c. 220 CE) contained ancient silk scrolls with references to 247 herbal substances used for medicinal purposes.

At the grave site of a doctor from the Later Han era (c. 25 to c. 220 CE), archaeologists found 92 wooden bamboo slips with pharmaceutical data which included a list of thirty prescriptions, referring to a hundred herbal medicines. These are believed to be the oldest written medical records in existence.

Excerpt and Photo From: "Early Texts of Traditional Chinese Medicine – An Ancient and Sophisticated Medical System", written by Leslie Cohen for Decoded Past. August 5th, 2013.  Full article can be found here: DecodedPast.com