Health Informatics Health Informatics professionals use technology to help patients and healthcare professionals. They design and develop information systems for medical records and insurance that ensure patient privacy and security. i.e. PASS (palm reader) 3.02 Understand health informatics

Health Informatics Professionals Communicate information Document information Analyze patient information Manage health information systems 3.02 Understand health informatics

Health Informatics Career Responsibilities 1. Communicate information File records Complete medical record forms Maintain accounting records 3.02 Understand health informatics 3 3

Health Informatics Career Responsibilities 2. Document information Obtain and record patient information Transcribe health information Complete and process insurance forms Must follow legal guidelines for documents 3.02 Understand health informatics 4 4

Health Informatics Career Responsibilities Documenting patient care requires: knowledge of medical terminology understanding of anatomy, physiology, and disease processes familiarity with pharmacology and laboratory tests

Health Informatics Career Responsibilities One career in health informatics is the medical transcriptionist transcribes health information dictated by physicians and other healthcare professionals into the patient’s medical record 3.02 Understand health informatics 6 6

Health Informatics Career Responsibilities 3. Analyze patient information Health Insurance Specialist completes and processes insurance forms Reviews charges Codes diagnoses and procedures Posts charges and payments to patients account 3.02 Understand health informatics 7 7

Health Insurance Claim Form CMS-1500 form (Centers for Medicare and Medicaid Services) Standard claims form used to request reimbursement for healthcare services from either a a third-party payer (insurance company) or government program (Medicare/Medicaid) 3.02 Understand health informatics 8

Health Informatics Career Responsibilities To complete the CMS-1500 form you must abstract and code patient information Abstracting refers to collecting information from a medical record. Coding refers to the assignment of a code to each of the patient’s diagnoses and procedures for the purpose of reimbursement 3.02 Understand health informatics

Health Informatics Career Responsibilities After abstracting information from the medical record, diagnosis and procedures must be coded for reimbursement Diagnosis codes are called ICD-9-CM Coding Procedure codes are called CPT Coding

Diagnosis Codes International Classification of Diseases (ICD) World Health Organization International Classification of Diseases (ICD) Codes aid in tracking the presence of disease US Department of Health and Human Services International Classification of Diseases Clinical Modification (ICD-CM) Used in diagnosis coding 3.02 Understand health informatics

Diagnosis Codes ICD-9-CM Coding The code book: Contains three volumes Volume 1 – numerical listing of conditions Volume 2 – alphabetical listing of the diseases Physicians’ offices and outpatient facilities use only Volumes 1 and 2 when coding 3.02 Understand health informatics

Diagnosis Codes ICD-9-CM Coding Main Term in Diagnosis is used to identify code Main term – condition causing the patient to be sick. Example: Urinary Tract Infection Infection is the main term in this diagnosis. 3.02 Understand health informatics

Diagnosis Codes ICD-9-CM Coding Basic Steps Locate the main term in the alphabetic index (Volume 2). Verify the code found in the alphabetic index in the Tabular List (Volume 1). Assign the correct code. 3.02 Understand health informatics

Procedure Codes CPT Coding (Current Procedural Terminology) Used to code medical procedures and services performed in outpatient facilities Has an index and a numerical listing There are 6 sections within the numerical listing. Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine 3.02 Understand health informatics

Procedure Codes CPT Coding The CPT index is organized by alphabetical main terms which include: procedures services organs anatomic sites conditions Eponyms (diseases named after a person/persons) abbreviations 3.02 Understand health informatics

Procedure Codes CPT Coding To use the code book: Go to the index, locate the procedure Ex: Rapid Strep Test Go to the numerical listing to determine which code is appropriate for the procedure listed in the charge form Assign the appropriate code number. 3.02 Understand health informatics