HI165 Seminar 2 HIM Department

Health Information Department Cancer registry Coding and abstracting Image processing Incomplete record processing Medical transcription Record circulation Release of information processing

Careers Cancer Registrars – Training College-based registry management programs – Credentials Certified Tumor Registrar (CTR) – Employment opportunities Cancer registries Consulting firms Private and government agencies

Careers Coding and Reimbursement Specialists – Training College-based – Professional Associations—AHIMA & AAPC Credentials Certified Coding Apprentice (CCA) Certified Coding Specialist (CCS) Certified Coding Specialist-Physician (CCS-P) Certified Professional Coder Certified Professional Coder-Hospital (CPC-H) – Employment opportunities

Careers Health Information Managers – Training College-based – Credentials Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) – Employment opportunities

Careers Health Insurance Specialists – Training – Credentials Electronic Claims Professional (ECP) Claims Assistance Professional (CAP) Associate, Life and Health Claims (ALHC) Fellow, Life and Health Claims (FLHC) Certified Medical Billing Specialist (CMBS) – Employment opportunities

Careers Health Service Managers – Training – Credentials Certified Nursing Home Administrator (CNHA) – Employment opportunities

Careers Medical Assistants – Training College-based – Credentials Certified Medical Assistant (CMA) Registered Medical Assistant (RMA) – Employment opportunities

Careers Medical Transcriptionists – Training Postsecondary education – Credentials Certified Medical Transcriptionist (CMT) – Employment opportunities

Other Career Opportunities Consultant Medical Office Manager Medical Staff Coordinator Privacy Officer Quality Manager Risk Manager Utilization Manager Vendor Salesperson

Role of the HIM Department in Record Completion Record assembly Quantitative analysis Qualitative analysis Concurrent analysis Statistical analysis

Confidentiality of Information and HIPAA Privacy and Security Provisions Privileged communication Confidentiality Privacy rule Security rule

Release of Protected Health Information (PHI) Patient record is a legal business record When authorization to disclose PHI is NOT required Patient access to records

ATHENS/Cerner PowerChart and HIM ProFile applications This electronic health record (EHR) system, designed specifically for academic use, includes more than 20 simulated hospital cases or charts. Lessons direct students in basic navigation of the electronic chart. Users can build their own “play patients,” allowing them to explore clinical and management tools and functions in the EHR, and build knowledge and skills in clinical information systems. This system also explores: Patient registration Clinical documentation tools and processes— – order entry – narrative and structured documents tools Clinical decision support tools (alerts and reminders) Deficiency management ROI's Electronic Chart Tracking Legal Concepts

QuadraMed MPI Suite The MPI software suite is for use in patient identity management and duplicate record management, and in maintaining database integrity. The database includes more than 50,000 patient demographic records, with approximately 5,000 potential duplicate sets. QuadraMed Smart ID is used for patient registration and prevention of duplicate records, while SmartMerge provides tools for duplicate management, including analysis and duplicate cleanup. Lessons explore the following topics and tools in the software: – Front-end registration – Tools for analysis of data integrity – Tools for resolving duplicate records – Duplicate management workflows and issues – Virtual management tools

QuadraMed Quantim Encoders (ICD-9 and ICD- 10) This knowledge-based encoder software includes ICD-9 and ICD- 10 diagnostic and procedure codebooks, CPT and HCPCS codebooks, and reimbursement groupers. Students can access extensive coding and general references, such as a medical dictionary, a drug reference guide, and anatomy illustrations, and can gain familiarity with encoder software tools and the resources they provide. The package includes: Encoder for coding practice Coding references Abstracting and compliance software Coded data set

3M Coding and Reimbursement System (ICD-9 and ICD-10) c 3M’s decision-based encoder software provides students with access to ICD-9 and ICD-10 diagnostic codebooks and procedure codebooks, CPT and HCPCS codebooks, and reimbursement groupers, and includes extensive coding and general references (a medical dictionary, a drug reference guide, and anatomy illustrations). Students gain familiarity with encoder software tools and the resources they provide. The 3M package includes: Encoder for coding practice DRG grouper for reimbursement concepts Extensive coding reference

McKesson Horizon Patient Folder Horizon Patient Folder is a document imaging system for managing health records that gives physicians, HIM personnel and other hospital staff anytime, anywhere access to review, analyze, code and complete electronic charts in their electronic medical records system. It allows HIM departments to become "virtual”, giving staff the ability to work remotely while letting authorized hospital personnel view patient records electronically. With student work queues set up for deficiency management and chart analysis activities, this creates a unique practice environment for students. Lessons provide students with opportunity to: Analyze charts for common "deficiencies" – Missing signatures – Missing text or dictation – Missing or misfiled documents Learn how software tools are used to identify and manage deficiencies