How does the author describe her career in HIM?

Author: Senior Enterprise Director, HIM, Coding, CDI

When my HIM career began 41 years ago, the three sectors of the revenue cycle were relegated to back-office paper pushers who selected the ICD-9-CM code of the day to submit for billing, as reimbursement was based on the number of days the patient stayed in the hospital and commercial payors paid what was submitted. Admitting offices had only a few forms, and the HIM department (then known as the medical records department) was largely separate from reimbursement or any of the admitting or billing processes and practices.

Where the rubber met the road and where my interest was piqued was with the advent of the prospective payment system (DRG system) in 1981. I took an active role and interest in all facets of this system as Director of Medical Records and became joined at the hip with the chief financial officer as we soaked up every morsel of information related to the new reimbursement system.

The floodgates soon opened; every payer wanted a discount, and some ventured into prospective payment. At this time, the Centers for Medicare and Medicaid Services (CMS) expanded prospective payment to other settings of care, starting with outpatient ambulatory payment classifications (APCs). A myriad of payer rules and requirements were developed to place the burden on providers to verify insurance coverage, obtain preauthorization, and satisfy the payer edits.

Over the years, my involvement in the revenue cycle grew from coding's role to the expansion into clinical documentation improvement (CDI). In 2015, I was provided with the opportunity to carve out a brand-new niche in the revenue cycle, revenue integrity. This functional area envelops all aspects of the revenue cycle and includes price transparency. I was also intimately involved with the shift from volume to value-based care, which required close collaboration with the quality team and a reinvigoration of the CDI program.

As a veteran HIM professional, I am proud of the prominent role we have carved out in the revenue cycle, and not just the mid-cycle. We influence and are active participants in all aspects of RCM and reimbursement. Our teams have also mastered the revenue cycle's analytical requirements to feed our teams the business intelligence needed to drive effective decisions to stay ahead of the payer and assure we are not leaving any money on the table. We lead our teams remotely, facilitated by well-oiled workflows either auto-prioritized or safe-guarded from cherry-picking, electronic resources, auto-suggested intelligence, and prominently displayed goals and metrics to guide our decision-making and actions.

During my journey to RCM excellence, I wish that I had had a primer to assist with me all aspects of revenue cycle management and reimbursement to guide and instruct me. Cherish the information that has been carefully curated in this book to enable you to master the most complex sector of healthcare. My gratitude goes to the authors for allowing me to contribute to this amazing body of knowledge.