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Chapter 29 Health Information

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

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. 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. 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. 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 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. 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 facility’s information system to create a client’s health record. Verify client’s eligibility for insurance coverage. Collect insurance co-payments. Check facts and records with the client’s primary care physician. Chapter 29

8 The Medical Biller Works in client accounting and reimbursement departments. 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 client’s 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. Chapter 29

10 The Health Unit Coordinator
Works at nursing stations in hospitals, nursing homes, rehabilitation facilities, and clinics. 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. 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. 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. 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. Chapter 29

15 The Medical Coder Assigns codes to client records.
Works in health information management departments of hospitals and other medical organizations. 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). 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. 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 transcribed reports to other physicians. 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). Chapter 29

20 The Privacy Officer (cont.)
Job Responsibilities Keep facility in compliance with applicable confidentiality laws. Analyze facility’s 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. 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. 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. 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. Chapter 29

24 Documenting Health Care 29-2
Diagnostic Coding Procedural Coding Verifying Billing Information 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. Chapter 29

26 Documenting Health Care (cont.)
Hospital Records The master patient index is the main database that identifies clients. It contains the client’s name, age, gender, address, admission date, and attending physician. Chapter 29

27 Documenting Health Care (cont.)
Hospital Records (cont.) A client’s record may contain: History and physical exam. Surgery report. Anesthesia report. Pathology report. Recovery room record. Graphic report. Discharge summary. Chapter 29

28 Documenting Health Care (cont.)
Documentation Standards Document every meeting with the following: Client’s 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. 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. Chapter 29

30 Diagnostic Coding Written diagnoses are assigned codes from a standard coding system. The most important diagnosis is the principal diagnosis. 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 Chapter 29

32 Diagnostic Coding (cont.)
Diagnoses are listed in 2 areas: Alphabetic Index and Tabular List. 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. Chapter 29

34 Procedural Coding Procedures, such as X ray and services, are assigned codes. 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. 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. 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. 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. 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. Chapter 29

40 Procedures in Student Text
29A Diagnostic Coding Practice 29B Procedural Coding Practice Chapter 29

41 Additional Procedures in Lab Activity Manual
LM29-1 Documenting Health Care LM29-2 Billing Review Chapter 29

42 Chapter 29 Credits Slide 17 Kathy Sloane/Photo Researchers Chapter 29

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