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

Chapter 29Health Information

Health Care Science Technology

Copyright © The McGraw-Hill Companies, Inc.

Chapter 292 Copyright © The McGraw-Hill Companies, Inc.

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.


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.


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.


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


The Health Care Receptionist

Works in client access departments in the registration or admissions area.

Helps clients who may be inpatients or outpatients.


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.


The Medical Biller

Works in client accounting and reimbursement departments.


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.


The Health Unit Coordinator

Works at nursing stations in hospitals, nursing homes, rehabilitation facilities, and clinics.


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.


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.


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.


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.


The Medical Coder

Assigns codes to client records.Works in health information

management departments of hospitals and other medical organizations.


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).


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.


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.


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).


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.




– 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.




– 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.


Section 29-1Apply Your Knowledge

What act governs the job of the privacy officer?

Answer:

The Health Insurance Portability and Accountability Act.


Documenting Health Care 29-2

Documenting Health CareDiagnostic CodingProcedural CodingVerifying Billing Information


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.


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.



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.



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.



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.


Diagnostic Coding

Written diagnoses are assigned codes from a standard coding system.

The most important diagnosis is the principal diagnosis.


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



Diagnoses are listed in 2 areas: Alphabetic Index and Tabular List.



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.


Procedural Coding

Procedures, such as X ray and services, are assigned codes.


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.



CPT Codes– Five-digit numbers, organized

into 6 sections.– Two-digit modifiers may be

assigned to the 5-digit code.



Procedural Coding Steps– Determine the procedures and

services to code.– Look up the procedure code.– Decide whether modifiers are

needed.


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.


Section 29-2Apply Your Knowledge

What does ICD-9-CM stand for?

Answer:

International Classification of Diseases, Ninth Revision, Clinical Modification.


Procedures in Student Text

29A Diagnostic Coding Practice

29B Procedural Coding Practice


Additional Procedures in Lab Activity Manual

LM29-1 Documenting Health Care

LM29-2 Billing Review


Chapter 29 Credits

Slide 17 Kathy Sloane/Photo Researchers

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