chapter 9 Flashcards
What do health information technicians/health information coders/ medical transcriptions do?
provide timely and accurate patient documents in an easy to use form
What paperwork is involved in a routine physical exam
history
summary of visit
possible lab test results
What do health information technicians do
gather paperwork
ensure paperwork is complete
assemble paperwork into well organized medical records
What did health information technicians evolve from
medical record administrators
Who was the first medical record administrator. Elaborate
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
When and what did the new name of the Association of Record Librarians of North America become
American Health Information Management Association (AHIMA)
1991
What happened in 1934 regarding AHIMA, what did this lead to
set first official standards for training programs
–> AMA began approving programs in 1942
Who approved AHIMA programs after the AMA did
the Commission on Accreditation for Health Informatics and Information Management Education
(CAHIM)
What happened in 1953 regarding AHIMA
standards were established for programs to train lower level workers (the medical record technician)
What have medical record technicians evolved into? What does this reflect
health information technicians
expansion of occupations role from dealing with one record to all records
What do entry level health information technician programs require
associates degree
What credentials can health information techs get
registered health information technicians (RHIT)
= 2 years associates degree program
= 20 CE per 2 years
= 80% of CE in health info. management
What 3 categories of health information courses are there
general education
professional education
practicum experiences
What do the duties of a health information tech depend on
the size of teh facility
What can health information techs specialize in
coding
cancer registry
What is health information tech: cancer registry
maintain databases for cancer patients
review patient records and assign codes for diagnosis and treatment
follow up with patients
What are the typical tasks of a health. info tech. (6)
- 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
What are 3 skills health info techs need
organization
detail oriented
communication
What are 3 factors for the increase in health info techs
more medical tests, treatments, procedures
elderly population aging
shift towards electronic records
What does the Ahima maintain for health info techs
a fellowship program
What do health information coders to
assign numerical codes to identify patient disease, injury, and conditions
codes are used by governmental agencies and insurance companies
When does medical coding date to
17th century, London during the bubonic plague
London published the ‘London Bills of Mortality’
Whose work advanced medical coding? Explain
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
what is mortality
fatal injury
what is morbidity
incidence of disease in population (all disease not just fatal disease)
What did WHO do in 1948
create a revised list of diseases incorporating both mortality and morbidity
International classification of Diseases (ICD)
What system of health information coding does the US use? what did they switch to in 2013
a clinical modification (CM) of the ninth revision aka ICD-9-CM
switched to ICD-10-CM
What is the education of a medical coder
on the job
few schools have associates degree programs that are not accredited
How many medical coding certificate programs are there
36
How much practical coding experience is needed for a medical coding certification
at least 40 hours
How much credentials does the AAPC (American Academy of Professional Coders) award
5 general credentials
19 specialty credentials
What 3 credentials require 2 yrs of medical coding experience by the AAPC
Certified Professional Coder (CPC)
Certified Professional Coder-Hopsital (CPC-H)
Certified Professional Coder-Payer (CPC-P)
What happens if you do not have coding experience and apply for one of the 3 2yr medical coding experience credentials
have apprentice status
What credential does the AHIMA offer for medical coders
Certified Coding Associate (CCA)
- need 10 CE and 2 annual coding self reviews every 2 years for renewal
also has 2 specialty/advanced credentials
What “lesser-known’ board awards credentials for medical coders
the Board of Medical Specialty Coding and the Professional Association of Healthcare Coding Specialists (PAHCS)
What two types of codes do health information coders work with
diagnostic codes
procedure codes
What are procedure codes based on
fourth edition of Current Procedural Terminology or CPT-4
by the AMA
What does the combination of procedure and diagnostic codes say
tells the insurance company what the patients medical problem was and what type of care the patient received
what is the newest trend in health care coding
computer assisted coding or CAC
- scans transcription files and predicts appropraite codes
What are the typical tasks of a health information coder (6)
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
What 3 traits do health information coders need
detail oriented
accurate
good learners
Why is health information coding increasing
rapid growth in medical tests, treatments, and procedures
What are the 3 professional organizations for health information coders
AAPC
AHIMA
Professional Association of Healthcare coding Specialists (PAHCS)
When did medical transcription begin
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
What happened in 1960 regarding medical transcriptionists
hospitals staffed medical transcription departments
What is a cost control measure for medical transcription
medical transcription is outsourced to medical transcription services in the US or overseas
What happened in 1978 regarding medical transcription
Association for Healthcare Documentation Integrity (AHDI) was formed
What happened in 1999 for medical transcription
US Department of Labor granted med. transcriptionists their own job classification
What is the education of medical transcriptionists
postsecondary training is encouraged but not needed
- 2 year associates
- or 1 yr certificate
Who offers optional approval for medical transcription programs
The Approval Committee for Certificate Programs
- joint committee of AHDI and AHIMA
What must medical transcriptionists do for a job
2400 minutes of actual transcription
What credentials (2) and designations (1) does the AHDI award
Registered Medical Transcriptionist (RMT)
- can apply for Registered Apprenticeship Program
Certified Medical Transcriptionist (CMT)
- higher than RMT
AHDI Fellow (AHDI-F)
What do you need for medical trasncriptionist renewal
online course and exam for RMT
30 CE for CMT
Describe earning an AHDI fellow
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
- membership
- professional meeting attendance
- leadership
- publications and presentations
- mentor-ship
- civic activities
- awards
- credentials
What is transcription being streamed over a network with?
PDAs or hand-held personal computers
What are he typical tasks of a medical transcriptionist (6)
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
What are two trends in medical transcription. these also serve as alternatives to using in-house medical transcriptions
outsourcing of transcription to foreign countries such as India and Pakistan
use of speech recognition technology
Why will medical transcriptions grow
increase in elderly
transition to electronic documentation
What is the professional organization for medical transcription
association for healthcare documentation integrity
