Health Information Management Overview

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Daphnee Fuentevilla

Salud y medicina Empresariales

Health
Information
Management
Overview
Meta Health Technology
16 January 2012

What is HIM?
© 2012, Meta Health Technology

Multiple healthcare settings
© 2012, Meta Health Technology
acute care & specialty
hospitals
physician offices
& clinics
long-term care facilities
rehabilitation &
ambulatory surgery centers
behavioral
& mental
facilities
government agencies &
insurance companiesHIM

Services provided
Coding
Clinical coding
(Inpatient & Outpatient:
Op Dx, Obs, ED, AS)
DRG Analysis
Case mix analysis
Auditing
Compliance
HIM Operations
Release of information
Chart completion
Chart assembly & filing
(paper)
Storage & retrieval of
medical records
Document imaging
(hybrid/electronic)
Transcription
Tumor registry
Birth & death certification© 2012, Meta Health Technology

Services provided
Clinical Documentation Improvement
Quality Care Support
 QA, UR, RM & Physician credentialing
© 2012, Meta Health Technology

© 2012, Meta Health Technology
Departmental structure

HIM Workflow (paper)
© 2012, Meta Health Technology

HIM Workflow (hybrid)
© 2012, Meta Health Technology

HIM Director
Privacy Officer
Compliance
Revenue Cycle
Medical Record Committee
Forms Committee
Performance Improvement
Budget & Finance
© 2012, Meta Health Technology

Coding
© 2012, Meta Health Technology
Credential: CCS All patient typesAccess to data Reimbursement
numeric code
780.60

Coding: commonly used terms
 DNFB (Discharged, Not Final Billed)
 DRG (Diagnosis Related Groups)
 Grouping
 Diagnoses & procedures
 ICD-9, ICD-10
 CPT/HCPCS
 Compliance, auditing, reporting
© 2012, Meta Health Technology

Chart retrieval
© 2012, Meta Health Technology
all accounted for
assembly & filing
(paper charts)

Document management
© 2012, Meta Health Technology

Transcription
© 2012, Meta Health Technology
Sample Reports
24 hr turnaround
required
Discharge
summary
History &
Physical
Operative
results
work from
home
outsourcedor

Chart completion
© 2012, Meta Health Technology
Post Discharge
Analysis
Notification
Reporting
“Completed” =
Signed
Dictated
Transcribed
Joint Commission
(accrediting agency)

Chart completion
“Record of Care” (RC) standards
History & Physical must be
completed within 24 hours of
admission
Discharge summary completed
& signed within 30 days of
discharge
Operative report completed
immediately after surgery
Physician orders time/dated &
signed
© 2012, Meta Health Technology

Release of information (ROI)
© 2012, Meta Health Technology
 Log & track requests
 Validate authorization
 Retrieve information
 Invoice requests
 Release record in accordance
with HIPAA & state statutes
 Report “accounting of
disclosures”
* The only revenue-generating
HIM function *

CDI
Clarify principal diagnosis
Capture MCC / CCs
Improve Documentation
© 2012, Meta Health Technology
Nurse RHIA / CCS CDI sheet

Present CDI focus
Clarification of principal
diagnosis
CC/MCC capture
Revenue generation: case
mix increase; return on
enhancement
Measurement: number of
generated queries,
physician response rate,
impact on revenue
Review for RAC DRGs
© 2012, Meta Health Technology

© 2012, Meta Health Technology
Questions

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In this lecture on circulatory shock, Dr. Faiza, an Assistant Professor of Physiology, delves into the profound implications of inadequate blood flow throughout the body, leading to tissue damage. The session begins by defining circulatory shock and elucidating its physiological causes, including decreased cardiac output, diminished blood volume, decreased vascular tone, obstruction to blood flow, excess metabolic rate, and abnormal perfusion patterns. Dr. Faiza categorizes shock into various types, such as cardiogenic shock, hypovolemic shock, neurogenic shock, obstructive shock, anaphylactic shock, and septic shock, and explores the pathophysiological basis of each. Furthermore, the lecture examines the stages of shock, from the non-progressive phase where compensatory mechanisms aim for full recovery to the progressive phase where shock worsens steadily without intervention, potentially leading to irreversible damage. Dr. Faiza discusses therapeutic interventions for shock, including replacement therapy, blood and plasma transfusion, sympathomimetic drugs, and other adjunctive treatments like head-down positioning, oxygen therapy, and glucocorticoids.

Circulatory Shock, types and stages, compensatory mechanisms

MedicoseAcademics

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Health Information Management Overview

1. Health Information Management Overview Meta Health Technology 16 January 2012

3. Multiple healthcare settings © 2012, Meta Health Technology acute care & specialty hospitals physician offices & clinics long-term care facilities rehabilitation & ambulatory surgery centers behavioral & mental facilities government agencies & insurance companiesHIM

4. Services provided Coding Clinical coding (Inpatient & Outpatient: Op Dx, Obs, ED, AS) DRG Analysis Case mix analysis Auditing Compliance HIM Operations Release of information Chart completion Chart assembly & filing (paper) Storage & retrieval of medical records Document imaging (hybrid/electronic) Transcription Tumor registry Birth & death certification© 2012, Meta Health Technology

11. Coding: commonly used terms  DNFB (Discharged, Not Final Billed)  DRG (Diagnosis Related Groups)  Grouping  Diagnoses & procedures  ICD-9, ICD-10  CPT/HCPCS  Compliance, auditing, reporting © 2012, Meta Health Technology

16. Chart completion “Record of Care” (RC) standards History & Physical must be completed within 24 hours of admission Discharge summary completed & signed within 30 days of discharge Operative report completed immediately after surgery Physician orders time/dated & signed © 2012, Meta Health Technology

17. Release of information (ROI) © 2012, Meta Health Technology  Log & track requests  Validate authorization  Retrieve information  Invoice requests  Release record in accordance with HIPAA & state statutes  Report “accounting of disclosures” * The only revenue-generating HIM function *

19. Present CDI focus Clarification of principal diagnosis CC/MCC capture Revenue generation: case mix increase; return on enhancement Measurement: number of generated queries, physician response rate, impact on revenue Review for RAC DRGs © 2012, Meta Health Technology

Health Information Management Overview

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