CCAStudyguideD1-6 PDF

Domain 1- Clinical classification systems 30-34% Time is: Amount of time when the healthcare provider is face-to face with the patient, Unit of time is based when the midpoint has passed, Time can be relevant to drug administration...

Domain 1- Clinical classification systems 30-34% Time is: Amount of time when the healthcare provider is face-to face with the patient, Unit of time is based when the midpoint has passed, Time can be relevant to drug administration as well Data Integrity Relies on patient identification of inaccuracies or data anomalies, ensures data is up-to-date and accurate. Data Cleanliness: Maintained through duplicate matching algorithms, data integrity teams, governance policies, integrity, education, and training. Official Sources when Coding Advised to use official sources when coding complicated procedures, and with “not sure” situations, these Reliable sources justify the coding so that accusations become invalid. They include American Hospital Associations (AHA) coding clinic for ICD 10, American Medical Association’s (AMA’s) CPT Assistant, Coders desk reference, 3m Nosology. Health Record Data for Abstraction Elements include: patient admit/discharge dates, discharge matching management notes, attending physician matching admit orders, and specific data points for newborn accounts, consulting information, and cause of death. Data Abstraction Extracting manually into a database or through manual paper abstraction relevant information from medical records for statistics, compliance, referrals, discharge information, and more. can be abstracted “if It hasn’t been documented it hasn’t been done”- The provider documents what they have done with procedures and diagnostics, this prevents denials, wins appeals, and prevents accusations of fraud. not documented-not done Superbill/ Encounter Form/ charge slip/ routing form A source document that collects information pertaining to Diagnostic and treatment & financial information Meaningful data Data is captured, queried and analyzed within the right format this helps with decision making, Quality, outcomes, payment methodologies. Data Dictionary: Contains field names, field types, tables, and reports based off data that has been collected making it reliable and usable. The goal is to achieve standardization of data elements between systems. Clinical Vocabulary (also called clinical nomenclature) list of clinical terms with their definitions/meanings/ preferred medical terms Outpatient Guidelines: Set rules for coders to follow in order to interpret and report procedures and services provided to the patient to help promote consistency ICD-10-PCS coding difference between upper and lower: Upper Body anything above the anatomical line between the two body locations Lower body: anything Lower the anatomical line between the two body locations Technical Component: (TC Modifier) Modifier that refers to Supplies, machine, operating room, equipment, non-physician staff Professional Component: Modifier Modifier that refers to the Physicians supervision of the service, reading, and interpreting test results Coder’s Role in CPT assignments Office or Clinic- physician will select based off a form- coder then transfers it to coders insurance form, but must review Medical record first- coders must verify accuracy of code based on Drs. notes 2 Types of Medical Coding Classification Systems Medical Coding Classification Systems Definition: a system that captures clinical data for reporting and reimbursement International Classification of diseases (ICD) identifies morbidity and mortality statistics (current version 10th) o Has 2 components-ICD-10-CM: Clinical Modification & ICD-10-PCS: Procedural coding system Current Procedural Terminology (CPT); used for the reporting of care delivered by physicians Healthcare Common Procedure Coding (HCPC) Diagnostic and Statistical Manual of Mental Disorders (DSM) Uniform Data Collection Process: Uniform Hospital Discharge Data Set est. in 1974 by Health and Human Services HHS: Establishes a minimum common core data set, abstracted during discharge for insurance claims form called o UB-04Elements include: personal Identification, admission/ discharge dates, types of admission, attending physician ID, operating Physician, Diagnosis, Procedures with dates, Patient’s deposition, and the expected payer. Ancillary services: o Diagnostic services from radiology and pathology that are provided by radiologist and pathologist who are physicians- coding guidelines states DO NOT ASSIGN BASED ON Results or reports. They must be validated by treating Physician. Resequencing codes: Can have positive or negative financial impact due to paying rate. If doesn’t support DRG, can be prosecuted for fraud. International Classification of Diseases- ICD-10-CM History Traced to 16th century from death record evidence by London. 1893 Bertillon Classification of diseases the renamed in 1900 to international Classification of causes of death until now 10th edition international classification of Diseases. 9th edition used for 36 years, 4 digit needed changes due to medical advances- needed to be able to grow with the times.  o Changes- New combination codes, added 7th character, expanded codes, trimesters in OB codes, time frames changed, definitions in notes. Needed a Procedure book so ICD-10-PCS was created- Can be 3-7 characters, 1st will always be a letter A-T then V-Z, no U. 2nd character will always be a number, 3rd character can be alpha or numeric, then the decimal is used, X is used as a place holder depending on how many characters required. Inpatient coding Principal Diagnosis (PDX): the “driver” behind the DRG- condition established after, and why they are admitted -Does not get assigned to Outpatient services only inpatient. Code sequencing: PDX must be highest level of specificity, followed by secondary, to find the sequence coder must review whole document and stay. Outpatient coding Primary Diagnosis: The reason that the patient is at the hospital, assigned to Outpatient service Conventions Please keep in mind that all the conventions, modifiers, symbols, etc. can be found at the front and throughout of the ICD-10- CM book. Always make sure you know where to find them and what the differences are. Knowing a general Idea of the differences, why you need them, what needs the modifier, where to find them, etc. will be very beneficial for you in the long run! Placeholder Character: “X”- allows for further expansion Seventh Characters-Some codes are very specific and need 7 codes Instructional type notes: o Inclusion Notes- includes o Exclusion notes o Excludes1 not coded here o Excludes2: not included here. o Code first o Use additional code notes, see also, or see condition. Abbreviations: o Not elsewhere classified (NEC) o Not otherwise Specified (NOS) Punctuation o () enclose supplementary words o [] synonyms or manifestation codes o : an incomplete term, needs more info Modifiers Purpose: Shows procedure has been modified or altered, more than one Physician conducted procedure and/or one location, Procedure/ Service needed additional work, Procedure/ Service was reduced, Same day Physician but separate procedure needed different E/M service, Bilateral locations, Done more than once. o Types - 2 digits-numeric, alpha, or alphanumeric, can be specified locations, Health status or Method of service, POA Indicators: Indicates which conditions are present on admission vs Hospital Acquired Conditions (HACs) Was it present on admission? o Y= Yes, it was present o N= No, it was not present o U= Unknown, not enough documentation to determine o W= clinically undetermined o 1= exempt from POA reporting Current Procedural Terminology- ICD-10-CPT History- ICD-10-CPT- Assigns codes for Procedures, services in office or outpatient office, surgery center. Published in 1966 by the AMA – updated annually o Has 6 Sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. o 13 Appendices: Modifiers, summary of add-ons, examples o Category II and Category III –: Supplemental/ Temporary codes o Alphabetical index-To code you locate this index. o Has 4 categories: Procedure or service, Organ or Anatomical site, Condition, Synonym/ eponyms/ abbreviations o Symbols Surgery Section Surgical Package/ Global surgery concept The range of services included in procedure/ operation. o Financial aspect: everything is bundled under the one correct CPT code. ▪ Includes: Anesthesia, E/M service – prior or day of, post op care, Physician orders, Post anesthesia care (recovery room time), Post op follow up DO NOT UNBUNDLE- Its fraud &/ or Medicare may have a different Surgery Package Book is organized According to Body Part categories are subdivided into- Organs, Anatomical sites, Procedure o Comprised of 7 Characters: Section, Body System, Root operation, Body Part, Approach, Device, Qualifier o Section- 0- Med/ surg, 1- Obstetrics, 2- Placement, 3 Administration  o Body System -Cardiology, respiratory, etc. o Root operation- Objective of procedure o Body Part- Where is it being performed? o Approach- Method used during procedure o Device -Device used, ex- implant o Qualifier -Additional information about the procedure. If the operation is discontinued- Find out how far that the procedure went then, Code by root operation. If it is stopped due to complications, code for inspection or a smaller root operation. 6 Root Operations Always with a device Insertion- addition of a non- biological device Replacement- Addition of a device that replaces a body part Supplement- Addition of a device that reinforces a body part Change- Exchange of a device Removal- Take out a device Revision- Modification or a malfunctioning device. 5 Root Operations Object is Pulled out/ off or a portion of a body part o Excision- Cut out/off a PORTION of a body part o Resection-Cut out/off ENTIRE body Part o Detachment: Cut out/off extremities only- Exclusive to amputations o Destruction: Eradicate/ destroy -Body part not removed rather destroyed o Extraction- Pull out with force, a portion of a body part or ENTIRE body part Coding for a Biopsy If a site needs more treatment- such as an excision of a part with a biopsy. you will code a biopsy and the more definitive treatment. Anesthesia Section Ranges from 00100-01999, Uses modifiers P1- P6 (overall health status) - Located at the front of the book & Provided by anesthesiologist or Certified Registered nurse anesthetist Services types -General, Regional, Local, Preoperative, Post-operative, monitoring of vitals, Administration of fluids, blood, drug, Organized by site Evaluation and Management- (E/M) Divided into Categories then subcategories All contain Format Similarities: Unique codes first, then place and or type, content of the service, problem, time Element with service/procedure Office Visits New patient- NOT received professional services from the same physician group within the last three years Established -Has received professional services from the same physician group within the last three years Does not apply to Emergency department Hospital Visits Initial- first time to hospital for that problem Subsequent- being seen again for the problem Consultations To code E/M visit: Review the instructions Make sure you have these coding elements for the visit specific category/ subcategory, E/M descriptors, determine extent of history, Level of examination, Level of decision making, Time spent with patient Document requirements outlined by AMA 7 components that make up the document: History, Examination, Medical Decision Making, Counseling, Coordination of care, nature of presenting problem, Time 1-History - Contributory element Factors: Chief compliant, History of present illness (HPI), Review of Systems (ROS), Past medical, family, and/or social history (PFSH) Inpatient documents -Emergency, Observation and Nursing Facility patient a certain amount of information contributes to the exam o Problem-Focused exam history: Minimum amount of info collected, very brief o Expanded problem-Focused: History requires the same & Needs Review of systems o Detailed: Extended HPI, Extended ROS, pertinent PFSH o Comprehensive: Most amount of data collected, Extended HPI, Complete ROS, Complete PFSH 2-Examination: Physical Examination- 4 types o Problem-focused- Limited to an affected body part/ organ, 1-5 Structures or functions of body part/ organ o Expanded problem-focused -Limited to an affected body part/ organ, 6 Structures/ functions of 1 or more body systems o Detailed exam -Extended Exam of body areas, At least 2 structures/functions in 6 organs, OR at least 12 structures or functions in 2 or more organ systems o Comprehensive exam -Multisystem Exam, At least 2 structures/functions in 9 organs, OR all structures or functions in the affected organ systems, AND at least 1 structure or function of the remaining organ systems. 3-Medical decision making: The complexity of establishing a Diagnosis has 3 categories o 1- Each individual test, document, or independent historian. 2- Independent interpretation of the test, 3-Discussion of management or test interpretation ▪ If a provider is reporting separately a test and its interpretation, the ordering and/or reviewing of such test cannot be credited in the amount and/or complexity of data reviewed when leveling an E/M o Decided based on the following: Number and complexity of problems addressed, Amount/ complexity of data reviewed; Risk of complications and/or Morbidity or mortality, Final element to be reviewed o Types of decision making: based off risk Straightforward, Low Complexity, Moderate complexity, High Complexity AMA defines risk as the probability/ consequences of an event, to find which is supported decision take the lowest of the two highest elements 4-Counseling: A conversation between the Physician and patient 5-Coordination of care: When multiple personnel are taking care of the patient. And they are coordinating together for a solution 6-Nature of presenting problem: Refers to disease, condition, injury, symptom, etc., May not have a Diagnosis determined when physician sees patient – 5 types o Minimal- Does not require the presence of a doctor but service is provided under their supervision o Minor- Problem that passes quickly and does not affect the patients’ health status permanently o Low severity- The risk associated with illness/ injury with no treatment is low full recovery is expected o Moderate severity - The risk associated with illness/ injury with no treatment is moderate and risk of death is moderate o High Severity - The risk associated with illness/ injury with no treatment is high and there is probable impairment to patient’s health status. 7- Time - How much time with patient determines level of E/M service o face to Face, you can locate the Code with the descriptions within your CPT book. Understand how to read the chart and what is needed from it. o Keep the following in mind ▪ 99211- may not require a Physician present ▪ +99417- additional 15mins of total time, list as an add on to 99215 and 99205 ▪ Non-Face-to-face time; when 2 providers discuss the patient, reviews test together, can be time spent traveling to office, teaching that isn’t related to specific patient, performing procedures separately reported. Medicare’s requirements for E/M Services Funds are protected under the Social security Act, will only reimburse for services that are reasonable and necessary, Provider’s responsibility to bill appropriate, Provider must not bill higher for services rendered at lower level, Documentation must be detailed, no fraudulent activity, They Will not pay for anything not supported with acceptable documentation Procedural Coding System (ICD-10-PCS) History: ICD-9 didn’t allow for growth needed more to keep up with technology & Now allows for long term growth ▪ Has 4 major attributes o Completeness-One code for each procedure o Expandability-Can incorporate new codes later o Multiaxial-Has independent characters that retains meaning o Standardized Terminology- All terms have one meaning Format Book has three Sections Tables, Index, List of Codes ▪ Tables: Designed in 2 Rows o Top-Reflects the 1-3 (from the index) o Bottom – uses characters 4-7- will have body part, Procedural approach, Device, Qualifier, doesn’t code straight across can move up and down, provides options for characters 4-7 of valid code combos ▪ Index: Alphabetic listing of procedures/operations, organized by type of procedure, only provides first 3-4 Characters of procedure code ▪ List of Codes: List of all procedural codes with descriptions To Code: Access the index, Locate the appropriate table, Reference table to locate remaining characters  Domain 2- Reimbursement methodologies: 21 – 25% Revenue Cycle Management: Three-part process: Claims processing, Payment Processing, Revenue generation Begins with determining patient eligibility, collecting copay/deductible, correcting claims, correcting charging of services, tracking claims between the provider and the payer o Factors impact revenue: Provider/ physician productivity, Patient volume (admission/Discharge/transfer Financial Reports DNFB – Discharged not final billed Helps with addressing high dollar amounts fast, old accounts Medical Necessity: Helps with getting important information for medical necessity NCCI edits: Resolves edit conflicts, by correcting codes or charges Adjudication: The process which submitted claims are evaluated by payer for determination of payment going to be rendered or not, can be accepted denied or rejected Accepted means claim is valid but may not reimburse in full- must be according to patients plan Denied- payor refuses to pay services Rejected- payer has found a claim error, and can be resubmitted Claims Starts with patient’s encounter, Services are rendered and charges entered, after discharge, documents are reviewed ICD-10 codes are added, Editing& corrections before being sent to clearing house, Payment is made by payer-Can be denied, and appealed if need be-Remittance advice is given to help or Explanation of Benefits for what it paid, lastly Collection of funds Falsified information/ incorrect will be denied and can be penalized 5k-11k per claim, felony, or prison Submitted by UB-04 or CMS-1500 o UB-04- universal claim form used by hospitals, hospices, home health, outpatient rehab, ESRD facilities, widely accepted by insurance, NUBC National uniform billing committee (NUBC) maintains it, has 81 fields o CMS-1500- CMS maintains it, has 33 fields, Reports provider/ physician services Claims adjustment Provider has made necessary adjustments, canceling 1st submission and replacing it Original inpatient claim submission is called TOB 131 (Type of Bill) Resubmitted claim TOB 137 Payment model types Fee- for-Service- Pay for the service done Value based delivery care- ACO’s share their value-based savings by managing patient’s health for less money Incentivized payment models- Rewards providers for meeting quality goals Payment bundling and Payment per case- DRGs Inpatient Prospective payment system (IPPS) Medicare’s payment system for acute care inpatient hospital stays its Regulated by CMS and updated annually to be compliant with the affordable care act, published in the Federal registrar  Medicate Severity Diagnosis Related Groups- (MS-DRGs) o Est. in 2007 to provider higher reimbursement for acute care treating severely ill patients than less severe, if an acute care serves a disproportionate number low-income patients’ hospital, they will receive and add-on payment & Can receive other additional add on payments, 3-tiered system that offers choices pertaining to Major Complications/ Comorbidities (MCC), Complications/comorbities (CC) and no complication/ comorbidity (non-CC) Hospital- Acquired Conditions (HAC) Condition that develops and affects the patient within hospital (ulcers, infection etc.), Complications o Identifying them provides and incentive by the HACRP (HAC Reduction Program) HAC Adjusts the payments to hospitals. if they are ranked badly they do not get an incentive & you can see ranking on medicare.gov Diagnosis-related groups (DRGs) Patients that are related based on: their diagnosis/conditions and treatment of the diagnosis/conditions, Lengths of inpatient stays, requires similar amounts of resources related to costs, Hierarchal they belong to base on major diagnostic categories (MDC) represent body system o MDC- Major Diagnostic Categories- Established for categorizing diseases and disorders by body system, medically or surgically Hierarchal Condition Category (HCC) Payment model used by Medicare Advantage Plans (Medicare Part C) to predict future costs over time, estimated on demographical location, types of illnesses, & Number of illnesses they have o Purpose to dispense higher reimbursement rates with chronic health conditions, the main Goal is to Encourage patients to seek treatment maintain health prior to a serious illness There are 19 coding categories, 86 HCC Codes, more than 9700 ICD-10-CM codes, Current HCC’s can be found on Medicare’s website Risk Adjustment Coding Physician’s documentation shows the risk of patient, impacts revenue because it determines the reimbursement for the provider o RAF- Risk Adjustment factor – Determines how much provider is reimbursed based on how ill the patient is Payer Matching Claims are submitted to Insurance Carrier, then scrubbed (checked for errors), if there are errors the healthcare entity will correct and then send back for review o Payer matching- a healthcare provider is enrolled with a clearing house, then assigned a payer ID #, that tells the clearing house which payer would receive the claim. Coordination of Benefits (COB) An individual is covered by more than one insurance plan, this document helps determine which insurance is primary and secondary- Primary gets billed, the rest then gets paid to secondary. Advance Beneficiary notice (ABN) (of noncoverage) A tool to notify that traditional Medicare beneficiaries that Medicare will most likely deny certain services, allows the patient to make an informed decision on whether or not to proceed with the service. MUST BE provided before service. It is signed if: the Service doesn’t meet medical necessity guidelines. Medicare has paid for a limited number of times within time frame, Service is for research. ABN-Cannot issue in the emergency room- interferes with EMTALA regulations - To file a claim for non-covered –( keep in mind) If they have the indicators they are always denied and the patient is liable. o Inpatient- can be reported to no pay claim, type of bill 110 o Outpatient- needs modifier GA or GX. ▪ GA- mandatory ABN was issued ▪ GX- voluntary ABN was issued Medical Necessity Invasive procedures and diagnostic studies should only be performed when they are medically necessary, determines if a payer will reimburse, & Needs a clear medical reason, (DX must support the procedure) Types Claim Denials- Denials happen when an insurance company stated that they will not pay the claim. Technical- a problem with claims processing Logic Based- code does not match a PCS code Unspecified Codes- needs more specificity – raises red flags with payers Medical Necessity- if medical necessity conditions are not met according to NCD & LCD Insurance Eligibility- payer bills the wrong insurance payer Modifiers- Modifier was misused Tracking Denials Spreadsheet- tracks reasons, follow-up status, Identifies areas responsible for it, and financial impact. Helps prevent denials in the future, benchmarking, and finances Generating Clean Claims Scrub claims before submitting, identifying errors, correct them, before submitting. Be familiar with payer edits & trending updates to regulations. Maintaining updated resources annually, providers need to be up to date on changes. NCDs and LCDs need to be updated and referenced. Analysis of the reasons to prevent them in the future If the Claim is denied/rejected by Medicare It Can be reconsidered, after revision, & with no errors. Provider checks Medicare’s common Working File, make sure its not been posted, access the Fiscal Intermediary Shared System for claims inquiry, as long as it isn’t within the history area it can be resubmitted. If provider disagrees, it can be appealed- each level has up to 180 days 5 levels of appeal o 1- redetermination o 2- reconsideration by a QIC o 3- if it needs to be presented to Administrative Law Judge o 4 Judicial review in federal court o 5-Appealed Medicare Code Edits (MCE Edits Help with coding accuracy, Invalid Diagnosis or procedure conflict- If doesn’t match valid codes , Age conflict- If it is impossible based on age group, Gender/sex conflict, Non-covered procedure-Not a covered service, Procedure with Limited coverage- Some procedures are too expensive and not fully covered. Appeals Appeals can be done on medical claims, but costs money to do file them, Always make sure they are clean first to prevent the denial and the need for an appeal, Average appeal cost is $20 and up, Policies should be in place to prevent costs adding up NCD & LCD You can locate them here- CMS.gov/Medicare-coverage-database- Has all statuses of both (proposed, future, retired, or current) CMS maintains a Medicare Coverage Database for both National Coverage Determinations (NCD) Published by Medicare, for services covered by Medicare at a national level for all MACs (Medicare Administrative Contractors, CMS determines if there is a need based on medical advancement/ technology to make an NCD, Takes 6-9 months for codes to become NCD Local coverage determinations (LCDS) Established by MAC for further guidance, especially if no NCD, LCD can become an NCD if approved, DRG Weights and impact on reimbursement Related conditions/ diseases of the IPPS system by SS Act: Each has unique weight based on – average amount of resources, Costlier are higher DRG, & Reimbursement weight- is weighed by labor, non-labor components, wage index factor, cost of living adjustment, & earnings by occupational category National Correct Coding Initiative (NCCI) Developed by CMS encourages coding methods, Part B claims only, Identifies the maximum number of units that can be billed under a single code. Coders- help with workflow process, they can reference MR documentation, identify inaccurate charges, makes recommendations helps with compliance Modifiers- Can be appended to CPT code. Can only be done if clinical documentation supports the addition of the modifier. NCCI Edit- tells you how many modifiers are allowed or not allowed. o Anatomical, surgical, and others can be added if guidance for the code in the edit table. ▪ 0= no modifiers are allowed ▪ 1= modifiers allowed. Ambulatory Payment Classifications (APCs) The packaging of items and services found within the Outpatient Prospective Payment System (OPPS) included are: Supplies, anesthesia, operating & recovery room, Ancillary services, devices/implants, drugs, lab tests, imaging services. They Can be located on CMS. Gov, updated annually, under Medicare fee-for-service payment, under addendum A & B & release date. o APCs have no impact on physicians’ services, & only done under outpatient discharged services, no admitting if they are admitted it changes to the IPPS. Outpatient clinics, ER, Observations, diagnostic, drug services and Outpatient services are covered. They are adjusted according to geographical location for the hospital, ICD-10-CM do not affect payment, but helps with medical Necessity, Claim has to be approved. CPT & Diagnosis codes linked together Both have to match up, otherwise it will be denied. Most payers notice first one only, can have multiple linked but must support the necessity of the procedure. One Dx coder can support multiple CPT codes. Ex.- an ankle fracture o Combination codes single code that represents two disease processes, or one dx with associated symptoms or even complication. Unbundling CPT Codes When 2 or more procedures should be reported together but they are reported separately, increases the providers revenue, but is illegal, Penalties are from the Office of Inspector General & Include fines, audits, imprisonment, exclusion from Medicare and Medicaid programs, Edits are done by CMS to reduce incorrect payments NCCI edits located on Medicare website o has 2 columns, describes cpt codes that should be coded together ▪ Edit 0 means they can be reported together ▪ Edit 1- reported together but with a modifier ▪ Edit 9 edit does not apply Resequencing Inpatient encounters can be re-sequenced for higher revenue o Section IIC in Official coding guideline of the selection of Principal Diagnosis- Used when 2 or more equally meet for Principal diagnosis & Has to be “worked up with diagnostic procedure. Promoting Clinical Documentation improvement opportunities Provide Communication on how it improves patient outcomes, quality score, contracts and reimbursement, Provide education and feedback, as well as medical necessity & Maintain a CDI programs Physician query processes o 4 w’s – who, what, why, when o Address compliance issues o Allows following up on unanswered questions  Domain 3- Health Records and Data Content :13-17% Master Patient Index (MPI) Data repository of all patients, that have been treated or admitted at a healthcare organization. Its a “source of truth” to locate records AHA requires patient info to be stored in MPI with their demographics, financial and clinical info o Duplicates- one patient has multiple MR o Overlay- two patients records are combined into one o Can be received from archives, Cannot be changed/deleted once achieved prior to retention policy, which ensures authenticity, Indexing and security is needed Retention Policy o Incorruptible format, (microfilm/ microfiche onsite or off), At least 10 years or per state laws , Influenced by federal and state Laws, Medicare, and statute of limitations. Data Mining o Helps retrieve health info data, All systems need to be interfaced, Can be built or purchased for filtering Medical Record Has a personal ID number to differ all patients apart Contains full history, surgical history, family history, demographics, Shots, drug allergies and medical directives o Patient Identification is number one key because it Prevents deaths, errors To request a record- Must be confidential by laws and policies o Release of information (ROI) processes are needed to ensure protection ▪ Authorization of disclosure must be issued: Requestors need government ID’s Electronic Healthcare Record (EHR) It is A record of the patients journey electronically, it must be able to maintain meaning for a lifetime, Items are assembled, by scanning, or manual entry. Once scanned they are shredded, Document quality control and indexing check the images, then they are processed through coding and deficiency management Big Data It’s the sheer volume of data available, the frequency that it is used, & has many forms Health Data standards Standardization of data elements- units with values. It is defined to the basic needs of What to collected, represented, and transmitted. Data formatting assists with electronic transmissions Physician notes Must include: Date & reason for visit, exam results, diagnosis of condition, preexisting, treatment plan, medications, education to the patient, and follow up Providers need training to assist these needs: Training can be one on ones, coding roundtables, peer-to-peer, pay for performance initiatives Health Information Exchange (HIE) Electronic method of accessing/ sharing patient information through portals, improves quality care, decision making, reduces medication errors & cost, duplicate testing- ARRA of 2009 –  incentive program to give money for adopting EHR, helps with meaningful use of technology - To improve quality care, coordination of care, privacy, engage patients Method of Access/sharing : o Direct- between providers to coordinate care o Query-based provider requests information for unplanned episode o Consumer-mediated- patients to control their use of PHI Office or the national Coordinator for HIT- (ONC)-Promotes HIE has guiding principals- sets Clear goals, measures of success, policies and standards, identifies issues, costs, allows patient to be in control of their health information HIM’s Roles- Data overseers, auditors financial, quality, and risk, reviews policies, creates patient information Healthcare Benchmarking Analyzes data to identify strengths and weaknesses for better performance, Entities can make comparisons, improves coding performance, and impacts revenue Data Validation Uses basic data, validates by analysis-Determines sources & types, develops a data dictionary, customary tools assist, provides data standardization, Audits are done to validate Data Abstraction Get important information from Medical record for statistical, reporting, compliance reasons Data Analytics Qualitative Analysis o Identifies deficiencies to inaccurate or incomplete information, justification for medical necessity, consent is provided, Must understand disease processes- types of disease, if clarification is needed, final decision may not be listed but needed, Impacts reimbursement and quality of care. Quantitative analysis o Identifies document deficiencies ▪ Resolved in