Coding, HIPAA, and PHI

Question 1

Types of Dispositions

Answer 1

1. Discharged
2. Admitted
3. Transferred

Question 2

Level 5 Billing for HPI, ROS, PMHx/SHx/FHx, PE

Answer 2

• HPI: 4 elements
• ROS: 10 elements or 2 with “all systems negative” box checked
• Past Hx: 2 elements
• PE: 8 elements (at least one finding in 8 different organ systems)

Question 3

Common critical care diagnoses

Answer 3

• MI
• PE
• CHF
• CVA
• A-Fib w/ RVR
• PTX
• Appendicitis (w/ rupture)
• GI bleed
• Sepsis
• Severe AMS,
• Meningitis
• DKA
• Acute renal failure
• Severely abnormal vital signs

Question 4

Common critical care procedures

Answer 4

• Intubation
• Chest tube
• Central line
• CPR
• Cardioversion
• CPAP/BiPAP

Question 5

What does HIPAA stand for? What is it?

Answer 5

Health Insurance Portability and Accountability Act

- Body of laws designed to protect the private health information of patients

Question 6

What does PHI stand for? What is it?

Answer 6

Protected Health Information

- ANY type of information that can be directly or indirectly tied to a particular patient or visit

Question 7

How are you affected by HIPAA/PHI?

Answer 7

You are not allowed to save copies of medical records, email them, store them outside of the hospital, or save them to external devices (USB/flash-drives) unless instructed to do so by the physician you are working with and save info to hospital approved devices

**You may NEVER save/transfer PHI of any kind to your personal email, smartphone, or any non-hospital approved device

Question 8

HIPAA Rules (8)

Answer 8

1. If a pt is not assigned to your doctor, do not touch the chart
2. There is always someone watching
3. Never share your username or password
4. No cell phones or pictures
5. Your job does not belong on social media
6. Do not store any PHI on non-approved systems
7. Do not access family, friend, or your own medical record
8. Ask yourself, “do I need to access this for my job?”

Question 9

ScribeAmerica rules/regulations (10)

Answer 9

1. Scribes cannot touch pts
2. Beware of provider entrapment
3. Remove yourself from unprofessional situations/conversations
4. Follow the dress code
5. You cannot enter the facility unless you have your badge and your own EHR login
6. No cell phones at work
7. Do not access family, friend, VIP’s or your own medical records
8. Never share your password
9. Do not post any work-related information on social media
10. Report all incidents to ScribeAmerica management

Question 10

What is HITECH?

Answer 10

Health Information Technology for Economic and Clinical Health Act

• Addition to HIPAA; addresses privacy/security issues related to electronic transmission of health information
• PHI cannot be transferred electronically without encryption

Question 11

Examples of PHI

Answer 11

• Patient name
• Geographic subdivisions
• Telephone numbers
• Email addresses
• Fax numbers
• Health Plan beneficiary numbers
• SSNs
• Certificate/license numbers
• Healthcare record numbers
• Account numbers
• Dates (except years)
• Any unique number/code/characteristic that can be linked to an individual