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Dynamics of Health Care > chapter 9 > Flashcards

chapter 9 Flashcards

1
Q

What do health information technicians/health information coders/ medical transcriptions do?

A

provide timely and accurate patient documents in an easy to use form

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2
Q

What paperwork is involved in a routine physical exam

A

history
summary of visit
possible lab test results

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3
Q

What do health information technicians do

A

gather paperwork
ensure paperwork is complete
assemble paperwork into well organized medical records

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4
Q

What did health information technicians evolve from

A

medical record administrators

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5
Q

Who was the first medical record administrator. Elaborate

A

Grace Whiting Meyers

was appointed in 1897 at Mass Gen Hospital to organize patient care records from the past 80 years

founded the Association of Record Librarians of North America in 1928

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6
Q

When and what did the new name of the Association of Record Librarians of North America become

A

American Health Information Management Association (AHIMA)

1991

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7
Q

What happened in 1934 regarding AHIMA, what did this lead to

A

set first official standards for training programs

–> AMA began approving programs in 1942

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8
Q

Who approved AHIMA programs after the AMA did

A

the Commission on Accreditation for Health Informatics and Information Management Education

(CAHIM)

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9
Q

What happened in 1953 regarding AHIMA

A

standards were established for programs to train lower level workers (the medical record technician)

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10
Q

What have medical record technicians evolved into? What does this reflect

A

health information technicians

expansion of occupations role from dealing with one record to all records

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11
Q

What do entry level health information technician programs require

A

associates degree

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12
Q

What credentials can health information techs get

A

registered health information technicians (RHIT)
= 2 years associates degree program
= 20 CE per 2 years
= 80% of CE in health info. management

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13
Q

What 3 categories of health information courses are there

A

general education
professional education
practicum experiences

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14
Q

What do the duties of a health information tech depend on

A

the size of teh facility

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15
Q

What can health information techs specialize in

A

coding

cancer registry

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16
Q

What is health information tech: cancer registry

A

maintain databases for cancer patients
review patient records and assign codes for diagnosis and treatment
follow up with patients

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17
Q

What are the typical tasks of a health. info tech. (6)

A
  • create paper or electronic chart
  • add documents to patient chart
  • make written entries in chart
  • file and retrieve charts
  • release authorized data
  • compute health care statistics
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18
Q

What are 3 skills health info techs need

A

organization
detail oriented
communication

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19
Q

What are 3 factors for the increase in health info techs

A

more medical tests, treatments, procedures
elderly population aging
shift towards electronic records

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20
Q

What does the Ahima maintain for health info techs

A

a fellowship program

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21
Q

What do health information coders to

A

assign numerical codes to identify patient disease, injury, and conditions

codes are used by governmental agencies and insurance companies

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22
Q

When does medical coding date to

A

17th century, London during the bubonic plague

London published the ‘London Bills of Mortality’

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23
Q

Whose work advanced medical coding? Explain

A

William Farr

  • created a uniform system of classification for mortality
  • partially adopted by the second International Statistical Conference in 1855
  • basis of International List of Causes of Death by the International Statistical Institute in 1893
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24
Q

what is mortality

A

fatal injury

25
Q

what is morbidity

A

incidence of disease in population (all disease not just fatal disease)

26
Q

What did WHO do in 1948

A

create a revised list of diseases incorporating both mortality and morbidity

International classification of Diseases (ICD)

27
Q

What system of health information coding does the US use? what did they switch to in 2013

A

a clinical modification (CM) of the ninth revision aka ICD-9-CM

switched to ICD-10-CM

28
Q

What is the education of a medical coder

A

on the job

few schools have associates degree programs that are not accredited

29
Q

How many medical coding certificate programs are there

A

36

30
Q

How much practical coding experience is needed for a medical coding certification

A

at least 40 hours

31
Q

How much credentials does the AAPC (American Academy of Professional Coders) award

A

5 general credentials

19 specialty credentials

32
Q

What 3 credentials require 2 yrs of medical coding experience by the AAPC

A

Certified Professional Coder (CPC)
Certified Professional Coder-Hopsital (CPC-H)
Certified Professional Coder-Payer (CPC-P)

33
Q

What happens if you do not have coding experience and apply for one of the 3 2yr medical coding experience credentials

A

have apprentice status

34
Q

What credential does the AHIMA offer for medical coders

A

Certified Coding Associate (CCA)
- need 10 CE and 2 annual coding self reviews every 2 years for renewal

also has 2 specialty/advanced credentials

35
Q

What “lesser-known’ board awards credentials for medical coders

A

the Board of Medical Specialty Coding and the Professional Association of Healthcare Coding Specialists (PAHCS)

36
Q

What two types of codes do health information coders work with

A

diagnostic codes

procedure codes

37
Q

What are procedure codes based on

A

fourth edition of Current Procedural Terminology or CPT-4

by the AMA

38
Q

What does the combination of procedure and diagnostic codes say

A

tells the insurance company what the patients medical problem was and what type of care the patient received

39
Q

what is the newest trend in health care coding

A

computer assisted coding or CAC

- scans transcription files and predicts appropraite codes

40
Q

What are the typical tasks of a health information coder (6)

A

assign diagnostic codes with ICD-9 CM or ICD-10

assign procedure codes with CPT or HCPS

monitor patient records for changes and update codes

investigate health payment details

assist in using coded data for reporting

coordinate coding info. with other HC professionals

41
Q

What 3 traits do health information coders need

A

detail oriented
accurate
good learners

42
Q

Why is health information coding increasing

A

rapid growth in medical tests, treatments, and procedures

43
Q

What are the 3 professional organizations for health information coders

A

AAPC
AHIMA
Professional Association of Healthcare coding Specialists (PAHCS)

44
Q

When did medical transcription begin

A

during the beginning of medicine as physicians would record data

physicians dictated notes to medical stenographers who would record them in shorthand

physicians began dictating into records, secretaries or specialized medical transcriptions would transcribe them

45
Q

What happened in 1960 regarding medical transcriptionists

A

hospitals staffed medical transcription departments

46
Q

What is a cost control measure for medical transcription

A

medical transcription is outsourced to medical transcription services in the US or overseas

47
Q

What happened in 1978 regarding medical transcription

A

Association for Healthcare Documentation Integrity (AHDI) was formed

48
Q

What happened in 1999 for medical transcription

A

US Department of Labor granted med. transcriptionists their own job classification

49
Q

What is the education of medical transcriptionists

A

postsecondary training is encouraged but not needed

  • 2 year associates
  • or 1 yr certificate
50
Q

Who offers optional approval for medical transcription programs

A

The Approval Committee for Certificate Programs

- joint committee of AHDI and AHIMA

51
Q

What must medical transcriptionists do for a job

A

2400 minutes of actual transcription

52
Q

What credentials (2) and designations (1) does the AHDI award

A

Registered Medical Transcriptionist (RMT)
- can apply for Registered Apprenticeship Program

Certified Medical Transcriptionist (CMT)
- higher than RMT

AHDI Fellow (AHDI-F)

53
Q

What do you need for medical trasncriptionist renewal

A

online course and exam for RMT

30 CE for CMT

54
Q

Describe earning an AHDI fellow

A

applicants must earn at least 50 points in the five years before applying

points must be earned in at least five of 8 categories including

  1. membership
  2. professional meeting attendance
  3. leadership
  4. publications and presentations
  5. mentor-ship
  6. civic activities
  7. awards
  8. credentials
55
Q

What is transcription being streamed over a network with?

A

PDAs or hand-held personal computers

56
Q

What are he typical tasks of a medical transcriptionist (6)

A

download and send files
transcribe a medical report
use references to check medical terms
edit proofread and format a transcription
query the professional who dictated the document
make corrections marked by the HC professional who dictated the document

57
Q

What are two trends in medical transcription. these also serve as alternatives to using in-house medical transcriptions

A

outsourcing of transcription to foreign countries such as India and Pakistan

use of speech recognition technology

58
Q

Why will medical transcriptions grow

A

increase in elderly

transition to electronic documentation

59
Q

What is the professional organization for medical transcription

A

association for healthcare documentation integrity

Dynamics of Health Care (21 decks)

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