1. Document information 3.02 Understand Health Informatics

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

3. Health Informatics Career Responsibilities
Document information
Obtain and record patient information
Obtaining patient information was discussed in the diagnostic and therapeutic services objective. In health informatics, this person might the admissions clerk.
3.02 Understand health informatics

4. Health Informatics Career Responsibilities
Document information
The medical transcriptionist transcribes health information dictated by physicians and other healthcare professionals into the patient’s medical record
Requires knowledge of medical transcription practices and legal guidelines
3.02 Understand health informatics

5. Health Informatics Career Responsibilities
Document information
Requires:
knowledge of medical terminology
understanding of anatomy, physiology, and disease processes
familiarity with pharmacology and laboratory tests
3.02 Understand health informatics

6. Health Informatics Career Responsibilities
Document information
Proofread Transcribed Reports
Evaluate punctuation
Evaluate spelling using spell check
Watch for sound alike words
Ex: hear/here; sight/site
Evaluate possible keying errors. Pay particular attention to numbers.
Use the print layout view to evaluate the entire page of your document.
3.02 Understand health informatics

7. Health Informatics Career Responsibilities
Document 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

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

9. CMS-1500 Health Insurance Claim Form

10. Health Informatics Career Responsibilities
Document information
Follow legal guidelines for documents
Maintain confidentiality of patient information
Ethical claims posted for insurance reimbursement
3.02 Understand health informatics

11. Communicate information 3.02 Understand Health Informatics

12. Health Informatics Career Responsibilities
Communicate information
File records
Use technology
Schedule appointments
Complete medical records forms
Maintain accounting records
3.02 Understand health informatics

13. Health Informatics Career Responsibilities
Communicate information
File records
Alphabetical
Numeric
Alphanumeric
3.02 Understand health informatics

14. Health Informatics Career Responsibilities Communicate information: file records
Alphabetic
Uses names
individuals
businesses
institutions
government agencies
subjects
topics
geographic locations
3.02 Understand health informatics

15. Health Informatics Career Responsibilities Communicate information: file records
Alphabetic
Files names on a unit-by-unit basis
Each part of the name is considered a separate unit
Each name must be compared letter by letter in order to place the names in proper sequence
3.02 Understand health informatics

16. Health Informatics Career Responsibilities Communicate information: file records
Numeric
Uses numbers in various combinations
Straight-numeric, consecutive
Duplex-numeric, two or more sets of numbers separated by dashes, commas, periods or spaces
Chronological uses numeric dates, year/month/date
Terminal-digit, the last digit is the primary unit
3.02 Understand health informatics

17. Health Informatics Career Responsibilities Communicate information: file records
Alphanumeric
Uses a combination of names and numbers
Once alphabetic divisions are made, number categories are assigned
Any number of combinations can be applied
3.02 Understand health informatics

18. Health Informatics Career Responsibilities
Communicate information
Use technology
3.02 Understand health informatics

19. Health Informatics Career Responsibilities
Communicate information
Schedule appointments
3.02 Understand health informatics

20. Health Informatics Career Responsibilities
Communicate information
Complete medical records forms
3.02 Understand health informatics

21. Health Informatics Career Responsibilities
Communicate information
Maintain accounting records
Asset records
Depreciation records
Inventory records
Records of accounts
Cash records
Payroll records
Tax records
3.02 Understand health informatics

22. Health Informatics Career Responsibilities
Manage health information systems
Combine the information systems used within a healthcare agency
Enable timely and accurate flow of information
Organize information
within guidelines
3.02 Understand health informatics

23. Health Informatics Career Responsibilities
Manage health information systems
Participate in the design of operational systems
Evaluate operational systems
3.02 Understand health informatics

24. Employment Opportunities in Health Informatics
Clinics
Laboratories
Home health facilities
Legal offices
Hospitals
Physician offices
Insurance companies
Transcription services
3.02 Understand health informatics

25. 3.02 Understand Health Informatics

26. Health Informatics
Health Informatics professionals treat technology as a tool that helps patients and healthcare professionals.
3.02 Understand health informatics

27. Health Informatics A career area that combines technology
healthcare science
communications
administration
business management.
Two areas of health informatics:
Management
Technical
3.02 Understand health informatics

28. Health Informatics: Management Duties
Design and develop information systems needed for medical records and insurance.
Develop policies and procedures for handling medical information to ensure patient privacy and security.
Manage budget.
Train users.
3.02 Understand health informatics

29. Health Informatics: Technical Duties
Design and develop information systems that operate between healthcare facilities
Integrate all medical records and insurance requirements into one system
Develop information systems that follow policies and procedures for handling information to ensure patient privacy and security
3.02 Understand health informatics

30. Health Informatics Professionals
Analyze patient information
Abstract and code patient information
3.02 Understand health informatics

31. Health Informatics Professionals
Document information
Communicate information
Manage health information systems
3.02 Understand health informatics

32. Health Informatics Career Responsibilities
Analyze patient information
Determine information required
Collect required information
Evaluate the information
Report and distribute information within legal guidelines
3.02 Understand health informatics

33. Health Informatics Career Responsibilities
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
Diagnosis codes
Procedure codes
3.02 Understand health informatics

34. Health Informatics Career Responsibilities
Abstract and code patient information
Collect information to record charges and reimbursements
Use appropriate medical terminology
Apply information for regulatory and legal purposes
3.02 Understand health informatics

35. Diagnosis codes Procedure codes
Coding:
Diagnosis codes Procedure codes
3.02 Understand health informatics

36. Diagnosis codes Procedure codes
Coding Refers to the assignment of a code to each of the patient’s diagnoses and procedures for the purpose of reimbursement
Diagnosis codes Procedure codes
3.02 Understand health informatics

37. Diagnosis Codes
ICD-9-CM Coding
3.02 Understand health informatics

38. 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

39. Diagnosis Codes ICD-9-CM Coding
Used to code the diagnosis
Must identify the main term in the diagnosis
Example: Essential hypertension
3.02 Understand health informatics

40. Diagnosis Codes ICD-9-CM Coding
The code book:
Contains three volumes
Volume 1 – Tabular List of Diseases
Volume 2 – Index to Diseases
Volume 3 – Index to Procedures and Tabular List of Procedures
Physicians’ offices and outpatient facilities use only Volumes 1 and 2 when coding
3.02 Understand health informatics

41. Diagnosis Codes ICD-9-CM Coding Continued
Volume 1
numerical listing of conditions
Volume 2:
alphabetical listing of the diseases
always found at the beginning of the code book
3.02 Understand health informatics

42. Diagnosis Codes ICD-9-CM Coding Continued
Main Term in Diagnosis
Main term – condition causing the patient to be sick.
Example: Urinary Tract Infection Infection is the main term in this diagnosis. Urinary Tract is the location of the infection and would not be the first place to look in the index (Volume 2).
3.02 Understand health informatics

43. Diagnosis Codes ICD-9-CM Coding
Complete
What’s the Main Term?
3.02 Understand health informatics

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

45. Complete the ICD-9-CM Coding handout

46. Procedure Codes CPT Coding

47. Procedure Codes CPT Coding
Used to code medical procedures and services performed in outpatient facilities
Has an index and a numerical listing
3.02 Understand health informatics

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

49. Procedure Codes CPT Coding
There are 6 sections within the numerical listing.
Evaluation and Management
Anesthesia
Surgery
Radiology
Pathology and Laboratory
Medicine
3.02 Understand health informatics

50. Procedure Codes CPT Coding
The CPT index is organized by alphabetical main terms which include:
procedures
services
organs
anatomic sites
conditions
eponyms
abbreviations
3.02 Understand health informatics

51. Procedure Codes CPT Coding
This is quite different from what you learned from the ICD-9-CM coding.
Reminder, with ICD-9-CM coding, you had to pick a main term. Not true with CPT coding
For this reason, most students like CPT coding over ICD coding
3.02 Understand health informatics

52. Procedure Codes CPT Coding Basic Steps
Review the procedure or service listed on the charge slip Ex: Rapid Strep Test
Locate the main term for the procedure or service.
Locate subterms and follow cross references.
Record all codes listed to be reviewed.
3.02 Understand health informatics

53. Procedure Codes CPT Coding Basic Steps
Review the description of procedure/service codes.
Record all codes listed to be reviewed.
Review the description of the procedure/service codes
Assign the appropriate code number.
3.02 Understand health informatics

54. Complete the CPT Coding handout
3.02 Understand health informatics

55. 3.02 Understand Health Informatics The End