health informatics career responsibilities document information obtain and record patient...

Document information

3.02 Understand Health Informatics

Health InformaticsCareer Responsibilities

Document informationObtain and record patient

informationTranscribe health informationComplete and process insurance

formsFollow legal guidelines for

documents

3.02 Understand health informatics 2


Document informationObtain and record patient

information



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



Document informationRequires:

knowledge of medical terminologyunderstanding of anatomy, physiology,

and disease processesfamiliarity with pharmacology and

laboratory tests



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

entire page of your document.3.02 Understand health informatics 6


Document informationHealth Insurance Specialist

completes and processes insurance formsReviews chargesCodes diagnoses and proceduresPosts charges and payments to

patients account


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)


CMS-1500 Health

Insurance Claim Form


Document informationFollow legal guidelines for

documentsMaintain confidentiality of patient

informationEthical claims posted for insurance

reimbursement


Communicate information

3.02 Understand Health Informatics


Communicate informationFile recordsUse technology Schedule appointmentsComplete medical records formsMaintain accounting records


Health InformaticsCareer ResponsibilitiesCommunicate information

File recordsAlphabeticalNumericAlphanumeric


Health InformaticsCareer ResponsibilitiesCommunicate information: file records

AlphabeticUses names

individualsbusinessesinstitutionsgovernment agenciessubjectstopicsgeographic locations



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


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



AlphanumericUses a combination of names and

numbers Once alphabetic divisions are made, number

categories are assignedAny number of combinations can be applied



Use technology



Schedule appointments



Complete medical records forms


Health InformaticsCareer ResponsibilitiesCommunicate informationMaintain accounting records

Asset recordsDepreciation recordsInventory recordsRecords of accountsCash recordsPayroll recordsTax records



Manage health information systemsCombine the information systems used within a

healthcare agencyEnable timely and accurate flow of informationOrganize information within guidelines



Manage health information systems

Participate in the design of operational systems

Evaluate operational systems


Employment Opportunities in Health Informatics ClinicsHome health

facilities HospitalsInsurance

companies

Laboratories Legal officesPhysician officesTranscription

services


3.02 Understand

Health Informatics

Health InformaticsHealth Informatics professionals treat

technology as a tool that helps patients and healthcare professionals.


Health InformaticsA career area that combines

technologyhealthcare sciencecommunicationsadministrationbusiness management.

Two areas of health informatics:Management Technical


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.


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


Health Informatics Professionals

Analyze patient information

Abstract and code patient information


Health Informatics Professionals

Document information

Communicate information

Manage health information systems



Analyze patient informationDetermine information required Collect required information Evaluate the informationReport and distribute information within

legal guidelines



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


Health InformaticsCareer ResponsibilitiesAbstract and code patient informationCollect information to record charges and

reimbursementsUse appropriate medical terminologyApply information for regulatory and legal

purposes


Coding:Diagnosis codes

Procedure codes


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


Diagnosis Codes

ICD-9-CM Coding


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


Diagnosis CodesICD-9-CM CodingUsed to code the diagnosis

Must identify the main term in the diagnosis


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


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


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).


Diagnosis Codes

ICD-9-CM Coding

Complete What’s the Main Term?


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.


Complete the ICD-9-CM Coding

handout

Procedure Codes

CPT Coding

Procedure Codes

CPT CodingUsed to code medical procedures and

services performed in outpatient facilitiesHas an index and a numerical listing


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


There are 6 sections within the numerical listing.Evaluation and ManagementAnesthesiaSurgery Radiology Pathology and Laboratory Medicine


Procedure Codes

CPT Coding

Procedure Codes

CPT CodingThe CPT index is organized by alphabetical

main terms which include: procedures servicesorgansanatomic sitesconditionseponymsabbreviations


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


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.


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.


Complete the CPT Coding

handout


3.02 Understand

Health InformaticsThe End

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