Health Informatics Career Responsibilities Communicate information File records Use technology Schedule appointments Complete medical records forms Maintain accounting records 3.02 Understand health informatics 2

Health Informatics Career Responsibilities Communicate information File records Alphabetical Numeric Alphanumeric 3.02 Understand health informatics 3

Communicate information: 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 4

Communicate information: 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 5

Communicate information: 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 6

Communicate information: 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 7

Health Informatics Career Responsibilities Communicate information Use technology 3.02 Understand health informatics 8

Health Informatics Career Responsibilities Communicate information Schedule appointments 3.02 Understand health informatics 9

Health Informatics Career Responsibilities Communicate information Complete medical records forms 3.02 Understand health informatics 10

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 11

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 12

Health Informatics Career Responsibilities Manage health information systems Participate in the design of operational systems Evaluate operational systems 3.02 Understand health informatics 13

Employment Opportunities in Health Informatics Clinics Home health facilities Hospitals Insurance companies Laboratories Legal offices Physician offices Transcription services 3.02 Understand health informatics 14

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 17

Health Informatics Career Responsibilities Document information Obtain and record patient information 3.02 Understand health informatics 18

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 19

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 20

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 Understand health informatics 21

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 22

CMS-1500 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 23

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 25

Health Informatics Health Informatics professionals treat technology as a tool that helps patients and healthcare professionals 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 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

Coding: Diagnosis codes Procedure codes 3.02 Understand health informatics 36

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 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 Diagnosis Codes ICD-9-CM Coding Used to code the diagnosis Must identify the main term in the diagnosis 3.02 Understand health informatics 40 Example: Essential hypertension

Diagnosis Codes 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 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 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) Understand health informatics 43

Diagnosis Codes Diagnosis Codes ICD-9-CM Coding Complete What’s the Main Term? 3.02 Understand health informatics 44

Diagnosis Codes 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 Understand health informatics 45

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

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 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 Understand health informatics 53

Procedure Codes 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 codes 8. Assign the appropriate code number Understand health informatics 54

Complete the CPT Coding handout 3.02 Understand health informatics 55