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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

http://www.findacode.com/search/search.php

http://icd9cm.chrisendres.com/

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


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 __________


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


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.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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


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 ____________________________


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. _______________________


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 ___________________


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


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.


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: _________________________


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


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


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.


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


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.


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


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


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


Documents

Speak clearly. - ewhshtr.pbworks.comewhshtr.pbworks.com/w/file/fetch/51138820/Handouts an… · Web viewTranslate the following patient scenario and rewrite the scenario using the