HIT Final

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created 5 years ago by jjeziorski2
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1

3M

Need principal diagnosis to begin coding

2

3M

DRG Grouper that uses ICD-9, 10, CPT

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3M

Encoder

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3M

Contains coding references

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3M

Uses American Hospital Association Coding Clinic for ICD-9-CM

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Cerner EHR - Power Chart

Billion dollar company out of Kansas City, MO

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Cerner EHR - Power Chart

Patient registration

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Cerner EHR - Power Chart

Electronic record system

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Cerner EHR - Power Chart

Creation of clinical documentation

CPOE must be in place before alerts will work

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Cerner EHR - Power Chart

Clinical decision support tools - alerts

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Cerner EHR - Power Chart

Hospital cases for coding practice

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Cerner EHR - Power Chart

Coding is done in Millennium

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Cerner EHR - HIM Profile

Deficiency management - missing signatures, notes, operative reports, and diagnosis

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Cerner EHR - HIM Profile

ROI - Release of Information

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Cerner EHR - HIM Profile

Electronic chart tracking - who looked at chart and when

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Healthport eSmartlog

ROI - Release of Information - release only the minimum necessary to fulfill request

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Healthport eSmartlog

Correspondence tracking

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Healthport eSmartlog

Request/Authorization/Record review for ROI

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Healthport eSmartlog

Process valid ROI requests - worker's comp, personal, legal

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Healthport eSmartlog

Generate correspondence letters for invalid ROI requests

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Quadramed MPI

Master Patient Index - authority file

Used to maintain the MPI

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Quadramed MPI

Front-End registration

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Quadramed MPI

Tools for analysis of data integrity

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Quadramed MPI

Tools for resolving duplicate records

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Quadramed MPI

Duplicates determined by deterministic, rules-based, or probabilistic algorithms.

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Nuance Quantim Encoder

Build codes with this software

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Nuance Quantim Encoder

Encoder for coding practice

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Nuance Quantim Encoder

Coding references - major references are CPT Assistant

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Nuance Quantim Encoder

Abstracting and compliance software

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Nuance Quantim Encoder

CPT assistant

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Nuance Quantim Encoder

Coded data set

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Nuance Quantim Encoder

Gathers pertinent information

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Nuance Quantim Encoder

Physician query

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EDCO Solcom EDMS

Read only chart repository for

  • Coding - can look up codes
  • Document retrieval - can look up by first name, last name, and other search methods
  • Deficiency management - are records deficient or not?
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Tableau

Data visioning software to help analyze documentation.

36

What is an encoder?

Computer software that helps the coding professional assign codes. Some are rule-based, or logic based, that prompt the coder through a series of questions whose answers lead to the correct code. Others are knowledge based and use more of an electronic code book by automating a look-up function similar to the manual index in ICD.

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Main Terms

What we look up. They are in bold and represent diseases, conditions, nouns, and adjectives.

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Subterms

or

Essential Modifiers

Read in combination with the main term.

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Nonessential Modifiers

In parentheses following the main term or subterm. The presence or absence of these terms in the diagnosis statement has no effect on the selection of the codes listed for that main term or subterm.

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ICD-10-CM contains

Chapters, categories, subcategories, and codes.

Chapters are subdivided into subcategories, or blocks of codes.

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ROI

Release of Information - Written request for information to be released. The request is entered into a system, validity is determined (Is form signed by patient, does authorization meet federal and state regulations?). If invalid, request is returned to sender with reason why. If valid, it is determined if person was patient at facility and record is released.

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Why are people requesting ROIs?

To know what's in them, check for identity theft, to keep track of their own records.

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What is in an ROI when released?

No more and no less than what fulfills the request.

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Where do ROIs come from?

Subpoena Duces Tecum

Worker's Comp

Patients

45

What is MPI?

Master Patient Index. The authority file that is a list or database created and maintained by a healthcare facility to record the name and identification number of every patient who has ever been admitted or treated in the facility.

It is the primary guide to locating pertinent demographic data about the patient and his or her health record number.

Without the information contained in this, it would be almost impossible to locate a patient's health record in most organizations that use a numeric filing system.

46

Coding references used within encoders

  • AHA Coding Clinic for ICD-9-CM and ICD-10-CM/PCS
  • AMA CPT Assistant
  • Clinical Pharmacology Drug Reference
  • Dorland’s Medical Dictionary
  • Elsevier’s Anatomy Plates
  • AHA Coding Clinic for HCPCS
  • Anesthesia Crosswalk
  • Coding handbooks for ICD-9-CM and ICD-10-CM/PCS
  • Mosby’s Manual of Diagnostic and Lab Tests
  • Dictionary of Medical Acronyms & Abbreviations
  • ICD-9 & 10 MS-DRGs Definitions Manuals
  • Merck Manual
  • Z’s Interval Radiology Coding Reference
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DRG

Diagnostic-Related Groups. Inpatient classification that categorizes patients who are similar in terms of diagnoses and treatments, age, resources used, and lengths of stay. Under the PPS, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the actual cost for the individual.

Each DRG is assigned a relative weight that is intended to represent the resource intensity of the clinical group and it is also used to determine the payment level for each group.

Only one DRG can be assigned and reimbursed for a single admission.

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What is EDMS?

Electronic Document Management System

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Why is EDMS important as we move towards electronic systems?

It's a way to manage the paper documents that go into an EHR.

Uses workflow management technologies to schedule and monitor work tasks, multimedia technologies and formats, and technology to move computer-generated content such as H&P or discharge summary from a transcription system to an EDMS without creating paper.

Medical transcription, lab results, and radiology results are most often electronically transferred to the EDMS.

50

What is an advantage to EDMS?

It can help manage work tasks. Workflow rules built into the system automatically identify the work tasks to be performed, how they should be routed, and sequences and dependencies among tasks.

For example, in management of record completion, as the status of dictation changes from dictate to transcribe to sign to signed, the status of the deficiency system is automatically updated without human intervention. At the same time, a request for dictation or review and signature is routed to the physician’s in-box.

51

What is a valid authorization?

The correct form must be signed by the patient that authorizes the facility to release the information requested. The facility must follow state and federal regulations regarding ROI. Substance-abuse treatment records, behavioral records, and HIV records require specific components to be included in the authorization form per state and federal regulations. Once the form has been determined to be correct, the facility may release only the information requested – nothing more, nothing less.

52

How does HIPAA relate to ROI?

HIPAA prohibits the release of any medical information for any reason unless the patient authorizes it or there is a subpoena duces tecum. Per HIPAA, a healthcare facility must maintain a record that accounts for all disclosures from the health record.

53

Ethics 7-Step Matrix used to resolve ethical dilemmas

  1. What is the ethical question?
  2. What are the facts? (Known and To Be Gathered)
  3. What are the values? Examine the shared and competing values, obligations, and interests of the stakeholders (patient, HIM professional, healthcare practitioners, administrators, society, and other advocates) involved in order to fully understand the complexity of the ethical problems.
  4. What are my options?
  5. What should I do?
  6. What justifies my choice? (Justified and Not Justified)
  7. How can I prevent this ethical problem?
54

Ethics

The formal process of intentionally and critically analyzing, with respect to clarity and consistency, the basis for one’s moral judgments.

55

Values

Principles, standards, or qualities considered worthwhile or desirable

56

Upcoding

Billing for a higher level of service than rendered on order to receive a higher reimbursement

57

Unbundling

Billing separately for each component of a procedure instead of using the proper code for the entire procedure because fees for the separate procedures result in a higher reimbursement

58

Fraud

An intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and that he or she nevertheless makes, knowing that the deception could result in some unauthorized benefit to the person who commits the act

59

Abuse

Incidents or practices of physicians or suppliers of equipment that, although not usually considered fraudulent, are inconsistent with accepted sound medical, business, or fiscal practices.