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.
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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.
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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.
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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
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6. The Health Care Receptionist
Works in client access departments in the registration or admissions area.
Helps clients who may be inpatients or outpatients.
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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.
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8. The Medical Biller
Works in client accounting and reimbursement departments.
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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.
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10. The Health Unit Coordinator
Works at nursing stations in hospitals, nursing homes, rehabilitation facilities, and clinics.
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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.
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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.
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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.
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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.
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15. The Medical Coder Assigns codes to client records.
Works in health information management departments of hospitals and other medical organizations.
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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).
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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.
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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.
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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).
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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.
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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.
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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.
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23. Section 29-1 Apply Your Knowledge
What act governs the job of the privacy officer?
Answer:
The Health Insurance Portability and Accountability Act.
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24. Documenting Health Care 29-2
Diagnostic Coding
Procedural Coding
Verifying Billing Information
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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.
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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.
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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.
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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.
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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.
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30. Diagnostic Coding
Written diagnoses are assigned codes from a standard coding system.
The most important diagnosis is the principal diagnosis.
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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
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32. Diagnostic Coding (cont.)
Diagnoses are listed in 2 areas: Alphabetic Index and Tabular List.
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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.
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34. Procedural Coding
Procedures, such as X ray and services, are assigned codes.
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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.
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36. Procedural Coding (cont.)
CPT Codes
Five-digit numbers, organized into 6 sections.
Two-digit modifiers may be assigned to the 5-digit code.
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37. Procedural Coding (cont.)
Procedural Coding Steps
Determine the procedures and services to code.
Look up the procedure code.
Decide whether modifiers are needed.
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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.
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39. Section 29-2 Apply Your Knowledge
What does ICD-9-CM stand for?
Answer:
International Classification of Diseases, Ninth Revision, Clinical Modification.
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40. Procedures in Student Text
29A Diagnostic Coding Practice
29B Procedural Coding Practice
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41. Additional Procedures in Lab Activity Manual
LM29-1 Documenting Health Care
LM29-2 Billing Review
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42. Chapter 29 Credits
Slide 17 Kathy Sloane/Photo Researchers
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