HEALTH INFORMATICS HEALTH SCIENCE II 1

JOB DUTIES OF HIM: COLLECT, ANALYZE, STORE INFORMATION (NOW DONE ELECTRONICALLY) CODING BILLING QUALITY ASSURANCE PROVIDE INFORMATION TO PHYSICIANS LABS,XRAYS,ECGS SURGERIES & OTHER PROCEDURES PHYSICAL DATA REVIEW FOR QUALITY ASSURANCE PURPOSES IMPROVE RESEARCH TECHNIQUES 2

CONFIDENTIALITY ALL INFORMATION GATHERED FROM OR ABOUT THE PATIENT IS CONFIDENTIAL HIM PERSONNEL MUST SIGN CONFIDENTIALITY AGREEMENTS WITH THEIR FACILITIES CLIENT INFORMATION CANNOT BE DISCUSSED WITH ANYONE EXCEPT HEALTH CARE PERSONNEL DIRECTLY CARING FOR OR SUPERVISING THE CARE OF THE PATIENT. FEDERAL LAW, HIPAA, GOVERNS FINES & PRISON TIME FOR VIOLATION OF THESE LAWS 3

TEAMWORK IN HEALTHCARE ADMISSIONS: REGISTERS PT. COLLECTS INS. PHYSICIANS EVALUATES,PRESCRIBES & TREATS NURSING SERVICES IMPLEMENTS TREATMENTS HIM HANDLES TRANSCRIPTION, CODING,RECORD MAINTAINENCE BUSINES OFFICE BILLS INSURANCE AND PATIENT 4

PLACES OF EMPLOYMENT HOSPITALS CLINICS URGENT CARE AMBULATORY CARE CENTERS PHYSICIAN’S OFFICES DENTAL CLINICS HOME HEALTH AGENCIES 5

HOSPITAL DOCUMENTS HISTORY AND PHYSICAL (H&P) GRAPHIC RECORD (VITAL SIGNS, HT. & WT. I&O) LABORATORY & OTHER REPORTS PATHOLOGY REPORTS SURGICAL REPORTS ANESTHESIA AND POST ANESTHESIA REPORTS DISCHARGE SUMMARY (HOME) OR TRANSFER SUMMARY (TO ANOTHER FACILITY) 6

DOCUMENTATION STANDARDS ACCURATE CLIENT INFORMATION: NAME, ENCOUNTER DATE & REASON H&P EXAM REVIEW OF TESTS ORDERED DIAGNOSIS PLAN OF CARE, NOTES ON TREATMENT GIVEN RECOMMENDATIONS/INSTRUCTIONS GIVEN TO PATIENT SIGNATURE OF PROVIDER WHO SAW PT. 7

DOCUMENTATION STANDARDS RECORDS MUST BE LEGIBLE COMPLETE & ACCURATE ENTRIES MUST BE SIGNED HANDWRITTEN OR TRANSCRIBED EACH ENTRY MUST HAVE A SIGNATURE & TITLE OF RESPONSIBLE PROVIDER CHANGES MUST BE MADE CLEARLY SINGLE LINE DRAWN THRU AND INITIALED ERASURES AND USE OF CORRECTION FLUID ARE NOT PERMITTED ON LEGAL DOCUMENTS DIAGNOSTIC INFORMATION MUST BE EASY TO LOCATE ENTRIES MUST BE MADE PROMPTLY 8

WHO OWNS THE MEDICAL RECORD? Medical records are the property of the health care facility or practitioner in private practice The contents of the information collected belong to the patient. Patients my view their records by contacting the Records Administrator No information can be released to anyone without the patients’ written consent. 9

10 THE END… FOR NOW !

CAREERS IN HIM HEALTH CARE RECEPTIONIST MEDICAL BILLER HEALTH UNIT COORDINATOR HEALTH INFORMATION TECHNICIAN MEDICAL CODER MEDICAL TRANSCRIPTIONIST COMPLIANCE OFFICER (PRIVACY OFFICER) 11

Medical Coder Assigns codes to client records using coding procedures & guidelines They review each record & find a client’s diagnosis Codes assigned determines how much the facilities gets paid Center for Medicare & Medicaid Services (CMS) assigns payment amount for average hospital stays based on Diagnosis-related-groups(DRG’s) Most insurance carriers base their payments on Medicare payments 12

Diagnostic Codes Scientists/researchers gather data from hospitals to learn more about disease process. A code number is assigned to each type of disease too ensure that the same terms are used by all The most important diagnoses is the Principle Diagnosis (reason the patient was admitted) 13

ICD-9-CM CODES International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Used by hospitals, has three sections; Volume 1- Diseases: Tabular List Volume 2- Diseases: Alphabetic Index Volume 3- Procedures: Tabular List & Alphabetic Index Volumes1 & 2 used to find the correct code for principle diagnosis Volume 3 used for hospital tests & treatments 14

PROCEDURAL CODING Procedures performed by healthcare personnel are assigned codes Current Procedural Terminology, Fourth Edition, (CPT) published by the American Medical Association Health Care Procedural Coding System, Level II (HCPCS) 15

VERIFYING BILLING Facilities creates a Chargemaster, lists of all services they can provide When client is discharged, the bill is calculated Bills are prepared on a standard government form called the UB-92 diagnosis codes client data list of each service 16