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3.02 Understand health informatics Name___________________ Handout Date ____________________Directions: Record notes and class discussion in your own words. Compare the ICD-9-CM and CPT codes as you view the PowerPoint presentation.
Health Informatics
Health Informatics
Management Duties1 2
3
4
Technical Duties1
2
3
4
Health Informatics
Professionals
1
2
3
4
5
Analyze patient information
1
2
3
4Abstract and code patient information
1
2
3
ICD-9-CM Coding CPT Coding
http://icd9cm.chrisendres.com/ http://www.findacode.com/search/search.php
7242 Health Science II Summer 2011 Page 229
3.02 What’s the Main Term? Name___________________ Handout Date ____________________
Directions: Using the ICD-9-CM for reference, identify and underline the main term in each diagnosis listed below.
1. Open fracture, maxilla
2. Congenital diaphragmatic hernia
3. Diaper rash
4. Dysplasia of the cervix
5. Sleep apnea
6. Intracranial abscess
7. Congestive heart failure
8. Acute cystitis
9. Chronic maxillary sinusitis
10. Impacted feces
11. Upper respiratory infection
12. Irritability of the stomach
13. Elevated blood pressure
14. Nontraumatic rupture of Achilles tendon
15. Diabetic cataract
16. Cushing’s Syndrome
17. Vitamin B12 deficiency
18. Trench mouth
19. Webbed toes
20. Intrinsic asthma in status asthmaticus
7242 Health Science II Summer 2011 Page 230
3.02 ICD-9-CM Coding Name ___________________ Handout Date ____________________
Directions: Use the ICD-9-CM Code book to assign the correct ICD-9-CM codes for the following diagnoses. Follow the Basic Steps of ICD-9-CM Coding.
1. Allergic diarrhea __________
2. Cholesterolosis of gallbladder __________
3. Urethral chancre __________
4. Cystic fibrosis __________
5. Congestive rheumatic heart failure __________
6. Viral meningitis __________
7. Cleft lip and palate __________
8. Pancytopenia __________
9. Infantile cerebral palsy __________
10. Anal fistula __________
11. Acne vulgaris __________
12. Dermatophytosis of the foot __________
13. Hiatal hernia with obstruction and gangrene __________
14. Mitral valve insufficiency __________
15. Monocytic leukocytosis __________
16. Lung mass __________
17. Prolapse of the bladder, female __________
18. Rupture of the gallbladder __________
19. Venereal warts __________
20. Gouty arthritis __________
7242 Health Science II Summer 2011 Page 231
3.02 Understand health informatics II Name___________________ Handout Date ____________________
Directions: Record notes and class discussion in your own words.
Document information
Career Responsibilities Class Discussion
Communicate information
Manage health information
systems
7242 Health Science II Summer 2011 Page 232
3.02 Using Medical Abbreviations Name ________________________ Handout Date ________________________
Directions: Translate the following patient scenario and rewrite the scenario using the definition of the abbreviation. Underline the definition.
Katie was admitted to the ED with complaints of FUO, N/V, and SOB. She had had nothing po because the sx became worse pc. A CBC, UA, and BS were ordered. An intravenous line was started and she was made NPO. Her TPR was normal but her P had increased. After a few hours, it was determined that she could be OOB and the order for BR was discontinued. She was placed on cl liq and received more than gtts for lunch. Her initial Dx of R/O salmonella was amended as she tolerated the liquids. When all lab work returned WNL, she was discharged. On the way out of the ED, she had to complete the paperwork with her DOB and was given a Rx for nausea.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
7242 Health Science II Summer 2011 Page 233
3.02 Medical Abbreviations Name ___________________Handout Class ___________________
a beforeac before mealsad lib as desiredax axillary BR bedrestBS blood sugarBSE breast self-examCBC complete blood countcl liq clear liquidsDNR do not resuscitateDOA dead on arrivalDOB date of birthDx, dx diagnosisED emergency departmentFUO fever of unknown origingtt dropNPO nothing by mouthN/V, N&V nausea and vomitingp afterP pulse OOB out of bedpc after mealspo by mouthR respirationR/O rule outROM range of motionRx treatmentSOB shortness of breathSx symptomT, temp temperatureTPR temperature, pulse, respirationUA, U/A urinalysisWNL within normal limits
7242 Health Science II Summer 2011 Page 234
3.02 Medical Abbreviations Quiz Name ______________________Handout Date _______________________
Directions: Write the meaning of the following abbreviations:
1. ad lib ____________________________2. ax ____________________________3. ac ____________________________4. BSE ____________________________5. DNR ____________________________6. DOA ____________________________7. R ____________________________8. ROM ____________________________9. T ____________________________10. UA ____________________________11. FUO ____________________________12. P ____________________________
Directions: Write the abbreviation for the following medical terms:
1. bedrest ____________________________2. blood sugar ____________________________3. complete blood count _______________________4. clear liquids ____________________________5. date of birth ____________________________6. diagnosis ____________________________7. emergency department _______________________8. drop ____________________________9. nothing by mouth____________________________10. nausea and vomiting _______________________11. out of bed ____________________________12. after meals ____________________________13. by mouth ____________________________14. respiration ____________________________15. rule out ____________________________16. range of motion____________________________17. treatment ____________________________18. shortness of breath _________________________19. symptom ____________________________20. temperature ____________________________
7242 Health Science II Summer 2011 Page 235
21. within normal limits _________________________
3.02 Proofreading Exercise Name ___________________ Handout Date ____________________
Directions: In the record below, circle misspelled words and identify missing words. Underline the misspelled words and write the corrected and missing words in the appropriate blanks. Consult medical and English dictionaries as necessary.
1. The labratory testing of blood, urine, and 1. ________________________
2. other body fliuds and waste products plays a 2. ________________________
3. miner roll in modern diagnostic medicine. 3. ________________________
4. The number of availabel tests increases 4. ________________________
5. almost daily, and the range of diseses and 5. ________________________
6. conditions able to be tested in labratory 6. ________________________
7. studys continually broadens. Some mention 7. ________________________
8. of labratory test results appears frequently 8. ________________________
9. in history, in physical examintion reports 9. ________________________
10. and nearly always in hospital discharge 10. _______________________
11. summarys. Accordingly the medical 11. _______________________
12. transcirptionist must be familiar with the 12. _______________________
13. general conceps of laboratory medicine as 13. _______________________
14. well as with pecific tests. Diagnostic 14. _______________________
15. labratory procedures may be called tests, 15. _______________________
16. studies, or simply work (“lab studies, “ “lab 16. _______________________
17. word”). Phisicians may report that they 17. _______________________
18. ordered, got, ran, did, or (in the case of 18. _______________________
19. blood work) drew a test. 19. _______________________
7242 Health Science II Summer 2011 Page 236
20. Crohn’s disease is a chronic dysorder 20. _______________________
21. which consists of inflamation of the 21. _______________________
22. gastrointestinal track. It is most commonly 22. _______________________
23. inflamation of the terminal ilium. The 23. _______________________
24. exact cause is unknown, but possible 24. _______________________
25. causes are allerges, imune 25. _______________________
26. disorders, and infections. Labratory tests 26 _______________________
27. have not detected any bacteria or virus 27. _______________________
28. responsable for causing Crohn’s disease. 28. ________________________
29. The patient experiences cramping, 29. _______________________
30. abdominal pain, nausea, diarrhea, 30. _______________________
31. abdominal tenderness, and weekness. 31. _______________________
32. Patience may be given intervenous fluids 32. _______________________
33. to provide nutrition while resting the bile. 33. _______________________
34. Some patients require surgery if the bile 34. _______________________
35. perforates,obstructs, or if there is 35. _______________________
36. massive hemorhage. 36. _______________________
3.02 Medical Insurance Key Terms Name___________________ Handout Date ___________________
7242 Health Science II Summer 2011 Page 237
Key Term Definition Student Notes
abstracting collecting information from a medical record
claims attachment medical report attached to the claim form substantiating a medical condition
coding assignment of a code to the patient’s diagnoses, procedures for the purpose of reimbursement
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification – coding system used to report diagnoses and reasons for encounters, such as an annual physical examination, on outpatient and physician office claims
CPTa Current Procedural Terminology – coding system published by the American Medical Association that is used to report procedures and services performed during outpatient and physician office encounters
3.02 Medical Insurance Key Terms page 2CMS Center for Medicare and
Medicaid Services – administrative agency within the
7242 Health Science II Summer 2011 Page 238
federal Department of Health and Human Services; responsible for the operation of Medicare and Medicaid
explanation of benefits (EOB)
report detailing the results of processing a claim (Ex: payer reimburses provider $80 on a submitted charge of $100)
health insurance claim form (CMS-1500)
documentation submitted to a third-party payer or government program requesting reimbursement for healthcare services provided
medical necessity linking every procedure or service code reported on the claim to an ICD-9-CM condition code that justifies the necessity for performing that procedure or service
preauthorization prior approval for treatment by specialists and documentation of post-treatment reports
remittance advice notice sent by the insurance company that contains payment information about a claim
3.02 Case Study – Name___________________ 7242 Health Science II Summer 2011 Page 239
Insurance Claim Forms Completion Date ____________________Handout
Complete a CMS-1500 claim form for each patient using their patient information form, copies of their insurance cards, charts and ledger cards.Use the information on the Patient Registration Form Handout and Documentation on Patient’s Medical Record to complete the claims for patients in a general surgeon’s office and family practice.
Physician Information
Group: Family Medicine and General Surgery Specialist, PA2222 Staton RoadAnyville, NC 27834
Federal Tax ID #: 56-412250
Physicians & Physician Insurance (PIN)#:
S. W. Jones, MD Medicaid #: 8974585Medicare #: 21022A
B. D. Thomas, MD Medicaid #: 8921333Medicare #: 22552A
Hospital: Generic HospitalP.O. Box 6028Anyville, NC 27000-6028
Insurance programs that the office participates in are Medicare, Medicaid, BCBS.
7242 Health Science II Summer 2011 Page 240
3.02 Patient Registration Form Name ___________________ Handout Date ____________________
Name: Jean Smith Social Security No: 244-44-4444
Street Address: 452 Farm Blvd
City, State, Zip: Anyville, NC 27828 DOB: 1-5-40
Phone: (H) (252) 753-5300 (W): (252) 753-5266 Sex: Female
Occupation/Employer: Perdue Physician: Jones
Spouse’s Name: John Smith Status: Married
Emergency Contact: Jane Smith
(Other than Spouse)
Emergency Contact Phone: 753-1111
Insurance Plan:
Prudential
Policy ID#:
YPP5689XX3
Group #:
37500
Secondary Policy:
Policy #: Group #:
Policyholder Name:
Amanda Dixon
Birthdate:
1-5-40
Relationship:
Self
Policyholder Name:
Birthdate: Relationship:
Assignment of Insurance Benefits
I hereby authorize direct payment of surgical/medical benefits to Dr. ___________________ for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance.
Authorization to Release Information
I hereby authorize Dr. ________________________ to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
Medicare-Medicaid
I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I request that payment of authorized benefits be made on my behalf.
A photocopy of these assignments shall be valid as the original.
PATIENT SIGNATURE: Amanda Dixon DATE: 01-01-06
PARENT/GUARDIAN (please print): _____________________________SIGNATURE: _________________________
7242 Health Science II Summer 2011 Page 241
3.02 Documentation on Patient’s Medical Record Name ___________________ Handout Date ____________________
Date Jean Smith Account # 4XXX HISTORY & PHYSICAL
10-15-07
10-16-07
11-4-07
11-5-07
Patient still having abnormal bleeding with the flow getting heavier each month. LMP 10-1-07, lasting 6 days, heavy with large clots. Heavy periods for the past year with increased pain and clots. Hemoglobin on last visit was 11.2
O: Uterus soft with fibroid uteri. Uterus increased in size. Also has cystourethrocele without a uterine prolapse.
Hemoglobin 9.0.
A: Menorrhagia, severe.Anemia.Fibroids, leiomyomata uteri.Cystourethrocele without uterine prolapse.
P: Schedule TAH-BSO, Marshall-Marchetti in 2 weeks.
S. w. Jones, MD
Scheduled TAH-BSO, Marshall-Marchetti for 11-4-07. LT/RN
Performed total abdominal hysterectomy with bilateral salpingo-oophorectomy with Marshall-Marchetti for the cystourethrocele.
S. W. Jones, MD
Patient discharged from the hospital to return to the office in three weeks for a recheck.
S. W. Jones, MD
7242 Health Science II Summer 2011 Page 242
3.02 Filing Records Name _______________Handout Date ________________
Alphabetic Filing All personal names are transposed so that the last name is the primary indexing
unit, first name second and middle name or initial is the third unit. April Smith Smith, April Jesse W. Brown Brown, Jesse W. If filing identical names, use the city and street names to place in alphabetical
sequence Don S. Clay, Asheboro, N. C. Clay, Don S. Asheboro Don S. Clay, Raleigh , N. C. Clay, Don S. Raleigh
Names with prefixes are filed disregarding punctuation and spacing within the surname Rena de la Santos de la Santos, Rena Amee La Croix La Crois, Amee David M. McArthur McArthur, David M.
Abbreviated names are files as though the names were spelled out. Chas. Malley Malley, Charles Charles L. Malley Malley, Charles L.
Professional titles and degrees are placed at the end of the name and enclosed in parentheses.
Organizations and Businesses in order they are written American, Red, Cross
Exception: If Owner's name is name of business, then follow name rulesThe T.S. Eliot Company is filed as Eliot, T., S., Company
Hyphenated names are considered as one unit After indexing, follow strict alphabetical order, use as many letters as needed to
file Nothing comes before something Numbers in a name are indexed as though they were spelled out
Numeric Filing Cross indexing (referencing) is required Patient names are indexed as for alpha filing Agency numbering usually runs in order, and a record is kept of which numbers
have been assigned. When patient comes to agency, alpha cross index is checked to locate patient's
file number Numbers go in order from small to large If zero falls before other numbers, the zero is disregarded when filing Many systems use the same terminal (last) digit for certain shelves or drawers - if
so - check the last digit and then put all the same last digits together
7242 Health Science II Summer 2011 Page 243
3.02 Alphabetic Filing Name ___________________Handout Date ____________________Directions: Index each patient’s name in the space provided. Put the names in alphabetic order in the space provided.
Indexed Names Alphabetic Names
123456789101112131415
Mary ChildersJohanna Q. MillerRev. Frank A. Mathews Sr.Dollar Tree, La Grange, N. C.Francis HaddockDollar Tree, La Grange, Il.Daniel L. BachSouth-West Auto ClubSusan B. Jordan, CPAJerri B. EvansWilliam Morris, Jr.Dollar Tree, La Grange, Ky.Southwest Regional AirportHans BradshawDr. Frank A. Mathews, Jr.
7242 Health Science II Summer 2011 Page 244
3.02 Numeric Filing Name ___________________Handout Date ____________________Directions: Place each group of numbers according to the numeric filing system in the space provided.
Straight Numeric Terminal Numeric123456789101112131415
1. 09248-972. 94009-983. 02736-914. 19985-985. 84755-986. 35594-997. 93747-928. 83790-999. 76630-9610.66655-9611.02836-9112.83610-9913.87330-9114.73660-9715.71740-92
7242 Health Science II Summer 2011 Page 245
3.02 Telephone Etiquette Handout
Answering the phone
1. Speak clearly.
2. Use your normal tone of voice.
3. Use proper language.
4. Address the caller by his/her title (Good morning Mr. Doe.)
5. Listen to the caller and what they have to say. Repeat information if you are taking a message to verify accuracy.
6. Be patient and helpful.
7. Always ask politely if you need to put someone on hold.
8. Always focus on the call. Try not to get distracted by others.
9. Do not eat or drink when talking on the phone.
Placing a call
1. Always identify yourself.
a. Name
b. Company name
c. Phone number
2. Always be aware of confidential information.
3. Always be aware of people around you. Be discreet.
4. Avoid leaving long messages. Keep it brief.
7242 Health Science II Summer 2011 Page 246
3.02 Scheduling Appointments Teacher Resource
Correct scheduling of appointments is essential for good public relations. Computerized systems specific to agency will be learned on the job.Appointment Procedures Vary from office to office Computer Scheduling
Computer automatically locates next available appointmentProvides a record of appointments already scheduledPrints out copies of daily schedule
Appointment book Time blocked in 15-minute intervals First…block out lunch, meetings, etc. with a large X Appointment time depends on purpose of appointment and would be determined by
the agency Some agencies use buffer period
When a patient calls…1. Find out reason for call2. Try to schedule convenient appointment for patient3. Try to give choices4. Be sure you have the required information before closing the call5. Spell names correctly (ask if you don't know)6. Write the patient's phone number in the appointment ledger7. Repeat the date, time and important appointment details8. Thank the caller and say good-bye9. Double-check appointment book to assure correct time was blocked off
If the patient calls to cancel…1. Ask if he/she would like to reschedule2. Erase/delete appointment and reschedule3. Do not ask why they are canceling
Scheduling issues…1. In many agencies, patients who don't show up are billed2. "No show" noted on patient's chart3. If an emergency occurs and the health care provider is called away, sometimes all
appointments must be canceled4. Sometimes, offices will make time for patients with emergencies to be seen
3.02 Maintain accounting records Teacher Resource
7242 Health Science II Summer 2011 Page 247
What is the purpose of financial records? Used to record and analyze the financial performance of a business.
What are financial statements? Reports that sum up the financial performance of a business.
Asset records name the buildings and equipment owned by the business, original and current value, and the amount owed if money was borrowed to purchase the assets.
Depreciation records identify the amount assets have decreased in value due to their age and use.
Inventory records identify the type and number of products on hand for sale/use.
Records of accounts identify all purchases and sales made using credit. An accounts payable record identifies the companies from which credit purchases were made and the amount purchased, paid, and owed. An accounts receivable record identifies customers that made purchases using credit and the status of each account.
Cash records list all cash received and spent by the business.
Payroll records contain information on all employees of the company, their compensation, and benefits.
Tax records show all taxes collected, owed and paid. As a part of payroll, employers must withhold a certain percentage of employees’ salaries and wages for federal income tax. The company also makes payments for Social Security and Medicare and, in some cases, for unemployment compensation.
3.02 Sample Budget Teacher Resource
7242 Health Science II Summer 2011 Page 248
South Hills Healthcare, P. A.123 American Boulevard,
Anytown, North Carolina 99999
Budget Actual Difference
Total Income $4,575,761.00 $3,303,137.00 $1,272,624.00
ExpensesEmployee Salaries $2,355,182.00 $2,358,346.00Drug supplies $17,473.00 $27,272.00Medical and Surgical Supplies
$64,768.00 $67,195.00
Pathology $6,716.00 $8,716.00Food Supplies $57,866.00 $53,828.00Domestic Services $49,766.00 $50,969.00Fuel, Light, Power, and Water
$67,245.00 $89,235.00
Insurance $68,849.00 $68,849.00Motor Vehicle Expenses
$28,114.00 $26,235.00
Repairs and Maintenance
$38,334.00 $30,103.00
Maintenance Contracts
$34,023.00 $34,023.00
Patient Transport $1,632.00 $1,632.00Other Administrative Expenses
$211,746.00 $167,339.00
Bad Debts $733.00 $1,733.00
Total Expenses $3,002,447.00 $2,985,475.00 $16,972.00
Net Income $16,795.00
7242 Health Science II Summer 2011 Page 249