Health Information Management Principles and Organization for Health Information Services,

Cover
Title Page
Copyright
Contents
About the Editor
About the Contributors
Preface
Acknowledgments
Chapter 1: Health Information Management and the Healthcare Institution
	Responsibility of the Board of Directors
	Responsibility of the President/Chief Executive Officer (CEO)
	Responsibility of the Medical Staff
		Credentialing and Privileges
		Authentication
	Functions of the HIM Department
	The HIM Professional
		Educational Requirements
		More on Certification
		Career Opportunities
		HIM Jobs
		New Role
		What Is HIM’s Role in Information Governance?
		Relationships with Other Departments
	Conclusion
	References
Chapter 2: Health Record Content and Structure of the Health Record
	Health Record Content
		Use of Abbreviations in the Health Record
		Joint Commission, Federal Conditions of Participation, and State Content Standards
		Inpatient Records
		Observation Patient Records
		Ambulatory Care Records
		Emergency Care Records
		Home Health Records
		Long-Term Care and Rehabilitation Records
		Hospice Records
		Behavioral Health Care
		Records in Other Healthcare Settings
		Secondary Health Data
	Master Patient Index
		Minimum Data Elements
		Back-Up Measures
	Disease and Operation Indexes or Databases
		Physician Index
	Registers Maintained by Healthcare Facilities
		Patient Register
		Birth and Death Registers
		Operating Room Register
		Emergency Department Register
		Special Registries
	Conclusion
	References
Chapter 3: The Health Record: Electronic and Paper
	Record Identification Systems
		Alphabetical Filing
		Numerical Identification
		Unit Numbering System
		Serial Numbering System
		Serial-Unit Numbering System
		Unique Health Identifiers
	Filing Systems for Paper-Based Records
		Alphabetical Filing
		Numerical Filing Systems
		Straight Numerical Filing System
		TD Filing
		Considerations in Filing Systems
		Miscellaneous Patient Forms
		Chart Requisition and Tracking Systems
	Logistical, Space, and Equipment Considerations
		The Permanent File
		Record Assembly and Analysis
		Coding and Abstracting
		Release of Information
		Medical Transcription
		Department Management
		Physician Record Completion
		Quality Assessment, Utilization Management, and Other Functions
		Additional Space and Equipment Considerations
	System and Equipment Selection
	Impact of the Electronic Health Record
	Health Information Management in Multisite Systems
	Conclusion
	References
Chapter 4: Healthcare Topics in Data Governance and Data Management
	Introduction
	Data Governance
	Data Management
	Working Examples/Case Scenario
		Discussion
	References
Chapter 5: Health Law, Data Privacy and Security, Fraud, and Abuse
	The U.S. Legal System
		Classifications of Law
	Sources of Law
		The U.S. Court System and the Legal Process
		The Legal Process
	Theories of Liability
		Breach of Contract
		Negligent Torts
		Intentional Torts
	Legal Requirements Affecting Health Information Management
		HIPAA: A Primer
		Privacy, Confidentiality, and Security
		Access, Use, and Disclosure
		Security of Electronic Protected Health Information
	Fraud and Abuse Implications for HIM and Corporate Compliance
		Fraud and Abuse in Health Care
		Fraud and Abuse Defined
		Laws to Combat Fraud and Abuse
		Role of Documentation and HIM Professional
	Conclusion
	References
Chapter 6: Informatics, Analytics, Data Use, and System Support
	The Field of Health Informatics
		Health Informatics: Defined
		History of Health Informatics
		Subspecialties of Health Informatics
	Data Analytics
		Data Analytics: Defined
		Sources of Data
		Why Collect and Analyze Data?
		Examples of Data Collection and Analysis in Health Care
	Application of Basic Statistical Techniques and Presentation of Data
		Types of Statistics
		Statistics Definitions
		Types of Statistical Data
		Healthcare Facility Statistical Terminology
		Healthcare Facility Rates
		Mortality Rates
		Autopsy Rates
		Presenting the Data
	Conclusion
	References
Chapter 7: Coding, Compliance, and Classification Systems
	International Classification of Diseases
		Background
		Development of the ICD-10-CM/PCS
		Oncology
		Mental Disorders
		SNOMED CT
		Current Procedural Terminology (CPT)
		ICD-10-CM/PCS and DRGs in Reimbursement
		DRGs and Their Application for Severity
		ICD-10-CM and Outpatient Reimbursement
	Coding Quality
		Coding Ethics and Optimization in Coding
		Compliance in Coding
	Challenges and Technology Advancements in Coding
	Conclusion
	References
Chapter 8: Clinical Documentation Improvement
	Managing Coding Audits
	Computer-Assisted Coding: A Review of Accuracy of CAC Coding Assignments
		Implement Provider Querying to Resolve Discrepancies
		How to Begin the Query Process
	Communicating with Physicians
		Physician Education
	CDI External Coding Audits
	CDI and the Case Mix Index
	Conclusion
	References
Chapter 9: Revenue Cycle and Reimbursement
	Administrative Functions of the Revenue Cycle
	Federal Regulation of Meaningful Use
	Lack of Consensus Regarding Interoperability Standards
	Information Governance
	Identity Theft
	Privacy and Security
	Security Breaches
	Healthcare Facilities Are Facing Collection Issues
		Negotiating Contracts with Commercial Payers
	Charge Description Master (CDM)
	Revenue Codes and the Form CMS-1450 (UB-04)
		Example of Revenue Codes
	Clinical Documentation Improvement (CDI)
	Necessity of a CDM Team
	Charge Capture
	Fraud and Abuse
	ICD-10-CM and ICD-10-PCS Required Restructuring of the Revenue Cycle
	Determination of Which Codes Are Placed in the Charge Master
	Clean Claim Submission
	Remittance Processing
	Denial Management
	Revenue Cycle Key Performance Indicators
	Conclusion
	References
Chapter 10: Strategic, Financial, and Organizational Management
	Utilize Health Information to Support Enterprise-Wide Decision Support
	Strategic Planning
	Develop Information Management Plans That Support the Organization's Current and Future Strategy and Goals
	General Principles of Management Utilized in the Administration of Health Information Services
	Health Information Exchange
		Use Cases
	HIM Contribution to HIE
	Budget Planning
		Types of Budgets
		Budgeting Principles
		Step in the Budget Cycle
	Overview Human Resources Including Labor/Employment Laws
		Future Roles of the HIM Professional
		Job Descriptions and AHIMA’s Career Map
	References
Index
EULA