Abstraction

Abstraction services benefit healthcare facilities and clinical departments that need high levels of data control, handling, and integrity. Here are the two areas of abstraction that we specialize in, and how we can apply them to your organization.

Areas of Abstraction

Core Measures

Core measures involve national standards of care and treatment. For your organization to be compliant, it must present data on these services, how often they’re administered, and under what circumstances. Abstraction helps you identify this information as well as areas for process improvement.

Medical Records

Your medical records contain data that can be used to improve health outcomes and lead to fewer health complications and readmissions. Abstraction catalogs these benchmarks, metrics, and courses of treatment through data collection that is timely, consistent, and accurate.

Why Outsource Abstraction

The healthcare industry understandably depends on strict rules and regulations, but that drive for compliance may hinder process improvement. A qualified data management company like HCRS has the resources to help organizations like yours a) meet industry standards, and b) gain valuable insight into your data for driving operational change.

Our Qualifications

Our Company

Our approach to abstraction has evolved from many years of experience with federal, state, and commercial healthcare practices. Our proven recruitment and retention plan gives us access to a talent pool across a diverse geography, including remote and saturated markets.

HIM Professionals

We consistently seek HIM (Health Information Management) and public health professionals who have previously worked in some facet of government health care. Each new abstractor meets all contractual requirements for experience, education, certification, security, health, and immunization, to include:

Two (2) years of experience within the respective service line: nursing, coding, physician reviews for medical necessity, programming, cybersecurity, etc.
Five (5) years of auditing and abstraction experience.

Our staffs are credentialed by approved governing bodies, such as the American Health Information Management Association (AHIMA) and/or American Academy of Professional Coders (AAPC), and are certified as one of the following:

Registered Health Information Administrator (RHIA).
Registered Health Information Technician (RHIT).
Certified Coding Specialist (CCS).
Certified Professional Coder (CPC).

Our Specialization

Our data abstraction and auditing specializes in:

COVID-19 surge validation, medical necessity, and claim audits.
Z-code data analysis for inpatient and outpatient discharge, with respect to social determinants of health.
Hospital Acquired Infections (HAIs).
Centers for Medicare & Medicaid Services (CMS) Measure and Instrument Development and Support (MIDS).
Payment Error Rate Measurement (PERM).
CMS Outcome and Assessment Information Set (OASIS).
Comparisons of nursing home quality measurements and overall star ratings.
Minimum Data Set (MDS) measurements.
International Classification of Diseases, 10th Edition (ICD-10).
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, (DSM-4).
Current Procedural Terminology, 4th Edition, (CPT-4).
Healthcare Common Procedure Coding System (HCPCS).
Diagnostic Related Groups (DRGs).
Berenson-Eggers Type of Service (BETOS).
Evaluation and management (E/M) codes.

Clients

Maryland Health Care Commission (MHCC). We support the Commission as a subcontractor to collect data and measurements for the Maryland State Quality Measures Data Center (QMDC). This includes validation of Cardiac Registry data submitted by 23 Maryland hospitals over a three-year timeframe. Our RN abstractors collect specified National Cardiovascular Data Registry (NCDR) data from both electronic and hardcopy medical records.

State of Maryland Health Services Cost Review Commission (HSCRC) Data Validation. Working closely with a prime contractor, HCRS provides validation of Hospital Acquired Infection (HAI) data collected from Maryland hospitals via the National Healthcare Safety Network (NHSN) system. Our team successfully executed a process that included auditor training, procedures for case selection, procedures for establishing a threshold for accepting a case as valid, execution of the audit plan, as well as provisions for hospital review and data resubmission.

Medicaid Integrity Contractor (MIC) Program. As a subcontractor, we conducted a comprehensive medical records review that included desk and field audits in 19 states west of the Mississippi and three Pacific territories. Our physicians, RNs, and coders conducted over 10,000 complex review audits per year for a total program duration of six years.

“If you are looking for an experienced and professional Health Information Services organization, then look no further than HCRS. Their services bring value and extraordinary quality to Johns Hopkins Hospital & Health System through their delivery of accurate, consistent and reliable diagnostic and procedural services”.

Louise M. Thompson, R.R.A., Administrator, HIM Johns Hopkins Hospital & Health System