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Chapter 29 Health Information Health Care Science Technology Copyright © The McGraw-Hill Companies, Inc.

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Presentation on theme: "Chapter 29 Health Information Health Care Science Technology Copyright © The McGraw-Hill Companies, Inc."— Presentation transcript:

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2 Chapter 29 Health Information Health Care Science Technology Copyright © The McGraw-Hill Companies, Inc.

3 Chapter 29 2 Objectives Summarize the key roles and responsibilities of a health care receptionist, medical biller, health unit coordinator, health information technician, medical coder, medical transcriptionist, and privacy officer.

4 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 3 Objectives (cont.) Identify the various settings in which health information professionals are employed. Clarify why it is important to keep client health care information confidential. Name the reasons for documentation standards.

5 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 4 Objectives (cont.) Identify the reference books used for coding health records. Categorize the steps in locating correct diagnosis and procedure codes. Give reasons for the importance of verifying clients bills. Successfully complete 2 health information procedures.

6 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 5 Careers in Health Information 29-1 The Health Care Receptionist The Medical Biller The Health Unit Coordinator The Health Information Technician The Medical Coder The Medical Transcriptionist The Privacy Officer

7 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 6 The Health Care Receptionist Works in client access departments in the registration or admissions area. Helps clients who may be inpatients or outpatients.

8 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 7 The Health Care Receptionist (cont.) Job Responsibilities – Help clients complete forms. – Check information the client provides. – Enter client financial and personal data into the facilitys information system to create a clients health record. – Verify clients eligibility for insurance coverage. – Collect insurance co-payments. – Check facts and records with the clients primary care physician.

9 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 8 The Medical Biller Works in client accounting and reimbursement departments.

10 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 9 The Medical Biller (cont.) Job Responsibilities – Make sure all client charges have been recorded in the billing system. – Enter data accurately into the clients accounts database. – Prepare claims to send to payers. – Prepare bills to send to clients. – Track payments due from payers and clients. – May specialize in Medicare bills.

11 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 10 The Health Unit Coordinator Works at nursing stations in hospitals, nursing homes, rehabilitation facilities, and clinics.

12 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 11 The Health Unit Coordinator (cont.) Job Responsibilities – Relay information to nurses, physicians, and workers in other departments. – Review clients health records. – Order diets, drugs, equipment, supplies, laboratory tests, and X rays for clients. – Type physicians orders. – Complete forms and reports related to admitting and discharging clients.

13 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 12 The Health Information Technician Health information management (HIM) departments maintain health record systems. – Analyze clients health records for accuracy and completeness. – Assign codes to clients diagnoses and procedures. – Prepare physicians reports.

14 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 13 The Health Information Technician (cont.) Job Responsibilities – Make sure clients have completed and signed all necessary forms. – Assemble forms and information in the health record. – Enter data about diagnoses, procedures, and charges into the information system.

15 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 14 The Health Information Technician (cont.) Job Responsibilities (cont.) – Highlight items in the record that are missing or confusing. – Ensure all hospital departments providing services to a client have finished their parts of the record. – Compare the payments with bills. – Prepare census and statistical reports.

16 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 15 The Medical Coder Assigns codes to client records. Works in health information management departments of hospitals and other medical organizations.

17 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 16 The Medical Coder (cont.) Job Responsibilities – Assign codes from standard code sets for procedures done. Payments are made based upon these codes. Codes have been developed from diagnosis-related groups (DRGs).

18 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 17 The Medical Transcriptionist Works in the health information management department of hospitals. Uses a transcribing machine to listen to dictation recorded by a physician or other health care worker.

19 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 18 The Medical Transcriptionist (cont.) Job Responsibilities – Accurately key in medical documents. – Log transcription telephone calls or internet transmissions. – Sort and distribute transcribed medical reports. – Correctly file typed dictation in clients records. – Fax or e-mail transcribed reports to other physicians.

20 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 19 The Privacy Officer Works in health care facilities, managed care organizations, and insurance companies. Must be knowledgeable regarding the Health Insurance Portability and Accountability Act (HIPAA).

21 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 20 The Privacy Officer (cont.) Job Responsibilities – Keep facility in compliance with applicable confidentiality laws. – Analyze facilitys risk of releasing information incorrectly. Set policies and procedures to avoid these risks. – Work with lawyers and managers to make sure that the organization has the appropriate privacy and confidentiality consent forms, information notices, and materials.

22 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 21 The Privacy Officer (cont.) Job Responsibilities (cont.) – Train staff members to understand and ensure privacy of client data. – Monitor all suppliers and business associate agreements to ensure that all privacy concerns, requirements, and responsibilities are met.

23 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 22 The Privacy Officer (cont.) Job Responsibilities (cont.) – Make sure that clients rights to inspect, amend, and restrict access to protected health information are observed. – Establish a process to investigate and take action on all complaints about privacy policies and procedures.

24 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 23 Section 29-1 Apply Your Knowledge What act governs the job of the privacy officer? Answer: The Health Insurance Portability and Accountability Act.

25 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 24 Documenting Health Care 29-2 Documenting Health Care Diagnostic Coding Procedural Coding Verifying Billing Information

26 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 25 Documenting Health Care All those working in health information work with health records. Health records are legal documents of treatment. Health information may be used in research and education.

27 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 26 Documenting Health Care (cont.) Hospital Records – The master patient index is the main database that identifies clients. It contains the clients name, age, gender, address, admission date, and attending physician.

28 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 27 Documenting Health Care (cont.) Hospital Records (cont.) – A clients record may contain : History and physical exam. Surgery report. Anesthesia report. Pathology report. Recovery room record. Graphic report. Discharge summary.

29 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 28 Documenting Health Care (cont.) Documentation Standards – Document every meeting with the following: Clients name. Date and reason for admission or exam. Medical history and physical exam. Review of all tests ordered. Diagnosis. Plan of care. Instructions or recommendations given to the client. Signature of provider.

30 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 29 Documenting Health Care (cont.) Documentation Standards (cont.) – Records must be legible. – Entries must be signed. – Changes must be made clearly. – Diagnostic information must be easy to locate. – Practitioners entries must be made promptly.

31 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 30 Diagnostic Coding Written diagnoses are assigned codes from a standard coding system. The most important diagnosis is the principal diagnosis.

32 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 31 Diagnostic Coding (cont.) The ICD-9-CM – International Classification of Diseases, Ninth Revision, Clinical Modification. Volume 1 – Diseases: Tabular List Volume 2 – Diseases: Alphabetic Index Volume 3 – Procedures: Tabular List and Alphabetic Index

33 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 32 Diagnostic Coding (cont.) Diagnoses are listed in 2 areas: Alphabetic Index and Tabular List.

34 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 33 Diagnostic Coding (cont.) Diagnostic Coding Steps – Both Alphabetic Index and Tabular List must be used to find the right code. – Find the Main Term of the Diagnosis in the Alphabetic Index. Main terms are bold-faced. Subterms are indented below the main terms. – Verify the Code in the Tabular List.

35 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 34 Procedural Coding Procedures, such as X ray and services, are assigned codes.

36 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 35 Procedural Coding (cont.) The CPT and HCPCS – Codes are assigned from the Current Procedural Terminology, Fourth Edition (CPT), published by the American Medical Association. – Hospitals also use codes from the Health Care Procedural Coding System, Level II (HCPCS), published by the federal government.

37 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 36 Procedural Coding (cont.) CPT Codes – Five-digit numbers, organized into 6 sections. – Two-digit modifiers may be assigned to the 5-digit code.

38 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 37 Procedural Coding (cont.) Procedural Coding Steps – Determine the procedures and services to code. – Look up the procedure code. – Decide whether modifiers are needed.

39 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 38 Verifying Billing Information Each hospital creates a chargemaster that lists all the services the hospital can provide, along with the procedure code and the charge for each service. Hospital bills are prepared on a standard government form called a UB-92 claim form.

40 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 39 Section 29-2 Apply Your Knowledge What does ICD-9-CM stand for? Answer: International Classification of Diseases, Ninth Revision, Clinical Modification.

41 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 40 Procedures in Student Text 29ADiagnostic Coding Practice 29BProcedural Coding Practice

42 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 41 Additional Procedures in Lab Activity Manual LM29-1Documenting Health Care LM29-2Billing Review

43 Copyright © The McGraw-Hill Companies, Inc. Chapter 29 42 Chapter 29 Credits Slide 17Kathy Sloane/Photo Researchers


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