Post on 26-Dec-2015
Health InformaticsCareer Responsibilities
Document informationObtain and record patient
informationTranscribe health informationComplete and process insurance
formsFollow legal guidelines for
documents
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Health InformaticsCareer Responsibilities
Document informationObtain and record patient
information
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Health InformaticsCareer Responsibilities
Document informationThe 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
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Health InformaticsCareer Responsibilities
Document informationRequires:
knowledge of medical terminologyunderstanding of anatomy, physiology,
and disease processesfamiliarity with pharmacology and
laboratory tests
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Health InformaticsCareer Responsibilities
Document informationProofread Transcribed Reports
Evaluate punctuationEvaluate spelling using spell check Watch for sound alike words
Ex: hear/here; sight/siteEvaluate possible keying errors. Pay
particular attention to numbers.Use the print layout view to evaluate the
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Health InformaticsCareer Responsibilities
Document informationHealth Insurance Specialist
completes and processes insurance formsReviews chargesCodes diagnoses and proceduresPosts charges and payments to
patients account
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Health Insurance Claim FormCMS-1500
Standard claims form used to request reimbursement for healthcare services.a third-party payer (insurance company) orgovernment program (Medicare/Medicaid)
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Health InformaticsCareer Responsibilities
Document informationFollow legal guidelines for
documentsMaintain confidentiality of patient
informationEthical claims posted for insurance
reimbursement
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Health InformaticsCareer Responsibilities
Communicate informationFile recordsUse technology Schedule appointmentsComplete medical records formsMaintain accounting records
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Health InformaticsCareer ResponsibilitiesCommunicate information
File recordsAlphabeticalNumericAlphanumeric
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Health InformaticsCareer ResponsibilitiesCommunicate information: file records
AlphabeticUses names
individualsbusinessesinstitutionsgovernment agenciessubjectstopicsgeographic locations
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Health InformaticsCareer ResponsibilitiesCommunicate information: file records
AlphabeticFiles names on a unit-by-unit basisEach part of the name is considered a
separate unitEach name must be compared letter by
letter in order to place the names in proper sequence
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Health InformaticsCareer ResponsibilitiesCommunicate information: file recordsNumericUses numbers in various combinations
Straight-numeric, consecutiveDuplex-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 isthe primary unit
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Health InformaticsCareer ResponsibilitiesCommunicate information: file records
AlphanumericUses a combination of names and
numbers Once alphabetic divisions are made, number
categories are assignedAny number of combinations can be applied
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Health InformaticsCareer ResponsibilitiesCommunicate information
Use technology
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Health InformaticsCareer ResponsibilitiesCommunicate information
Schedule appointments
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Health InformaticsCareer ResponsibilitiesCommunicate information
Complete medical records forms
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Health InformaticsCareer ResponsibilitiesCommunicate informationMaintain accounting records
Asset recordsDepreciation recordsInventory recordsRecords of accountsCash recordsPayroll recordsTax records
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Health InformaticsCareer Responsibilities
Manage health information systemsCombine the information systems used within a
healthcare agencyEnable timely and accurate flow of informationOrganize information within guidelines
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Health InformaticsCareer Responsibilities
Manage health information systems
Participate in the design of operational systems
Evaluate operational systems
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Employment Opportunities in Health Informatics ClinicsHome health
facilities HospitalsInsurance
companies
Laboratories Legal officesPhysician officesTranscription
services
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Health InformaticsHealth Informatics professionals treat
technology as a tool that helps patients and healthcare professionals.
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Health InformaticsA career area that combines
technologyhealthcare sciencecommunicationsadministrationbusiness management.
Two areas of health informatics:Management Technical
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Health Informatics: Management DutiesDesign 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.
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Health Informatics:Technical DutiesDesign and develop information systems that
operate between healthcare facilitiesIntegrate all medical records and insurance
requirements into one systemDevelop information systems that follow
policies and procedures for handling information to ensure patient privacy and security
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Health Informatics Professionals
Analyze patient information
Abstract and code patient information
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Health Informatics Professionals
Document information
Communicate information
Manage health information systems
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Health InformaticsCareer Responsibilities
Analyze patient informationDetermine information required Collect required information Evaluate the informationReport and distribute information within
legal guidelines
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Health InformaticsCareer Responsibilities
Abstract and code patient informationAbstracting 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 reimbursementDiagnosis codesProcedure codes
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Health InformaticsCareer ResponsibilitiesAbstract and code patient informationCollect information to record charges and
reimbursementsUse appropriate medical terminologyApply information for regulatory and legal
purposes
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CodingRefers to the assignment of a code to each of the patient’s diagnoses and procedures for the purpose of reimbursement
Diagnosis codes
Procedure codes
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Diagnosis CodesWorld 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
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Diagnosis CodesICD-9-CM CodingUsed to code the diagnosis
Must identify the main term in the diagnosis
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Example: Essential hypertension
Diagnosis CodesICD-9-CM CodingThe 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
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Diagnosis CodesICD-9-CM Coding Continued
Volume 1numerical listing of conditions
Volume 2:alphabetical listing of the diseasesalways found at the beginning of the code book
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Diagnosis Codes
ICD-9-CM Coding ContinuedMain Term in DiagnosisMain 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).
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Diagnosis Codes
ICD-9-CM Coding
Complete What’s the Main Term?
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Diagnosis CodesICD-9-CM Coding Basic StepsLocate 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.
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Procedure Codes
CPT CodingUsed to code medical procedures and
services performed in outpatient facilitiesHas an index and a numerical listing
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Procedure Codes
CPT CodingTo use the code book:
Go to the index, locate the procedureGo to the numerical listing to determine which
code is appropriate for the procedure listed in the charge form
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There are 6 sections within the numerical listing.Evaluation and ManagementAnesthesiaSurgery Radiology Pathology and Laboratory Medicine
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Procedure Codes
CPT Coding
Procedure Codes
CPT CodingThe CPT index is organized by alphabetical
main terms which include: procedures servicesorgansanatomic sitesconditionseponymsabbreviations
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Procedure CodesCPT 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
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Procedure Codes
CPT Coding Basic Steps
1. Review the procedure or service listed on the charge slip Ex: Rapid Strep Test
2. Locate the main term for the procedure or service.
3. Locate subterms and follow cross references.
4. Record all codes listed to be reviewed.
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Procedure Codes
CPT Coding Basic Steps
5. Review the description of procedure/service codes.
6. Record all codes listed to be reviewed.7. Review the description of the
procedure/service codes8. Assign the appropriate code number.
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