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Management of Health Information
Assignment Requirements
Create a PowerPoint presentation with a minimum of 5 slides, in addition to the title slide and reference slide.
Create a word document which should be at least 800 words in length to correspond with your PowerPoint presentation.
Your written word document and PowerPoint presentation should include the items listed below. Note that the PowerPoint presentation should reflect the key points of the written paper, which is the formation to be conveyed in the virtual meeting.
Quoting should be less than 10% for each submission. Paraphrasing is necessary.
Students must provide in-text citations and reference at least 4 credible sources from the library or other resources such as Google Scholar.
Instructions
As the Director of Health Information in a large health system, you have been tasked to prepare for a compliance audit by the CEO and Board of Directors. This will involve scheduling a departmental meeting, but many of the employees telecommute. In order to ensure all employees are able to participate, you will need to plan a virtual meeting. You will develop a PowerPoint presentation that will be used in that meeting. Your PowerPoint presentation should include the items listed below.
In addition to your textbook and the University library, the following resources will be beneficial in gathering information for your presentation:
Centers for Medicare and Medicaid Services https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets/index.html
AHIMA Body of Knowledge http://bok.ahima.org/PdfView?oid=71473
UHDDS and Federal compliance guidelines, Official coding guidelines from CMS, AMA, National Committee on Vital and Health Statistics (NCHVS), the National Correct Coding Initiative (NCCI), and AHA.
Part
Instructions
1
Distinguish the difference between a classification system and medical vocabulary and terminology and explain what a HIPAA code set is. Choose three (3) classification systems identifying the functions and relationships among these systems. (Examples include but are not limited to ICD-10-CM/PCS, ICD-O-3, ICF, ICPC-2)
2
Develop a chart and use it to illustrate mapping of standard clinical terminology to a HIPAA code set. You should provide a three (3) examples. (Examples include but are not limited to LOINC to CPT, SNOMED to ICD, one code set to another code set)
3
Construct two (2) policies, processes and procedures to ensure the accuracy of coded data based on established guidelines and provide justification as to their importance.
Example of a policy/procedure template: http://www.hpso.com/Documents/Risk%20Education/Businesses/PolicyProcedureTemplateGuide.pdf
(not mandatory to use)
4
One of the policies and processes listed in #3 should include managing coding audits incorporating audit principles and reporting processes.
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Management of Health Information
Part 1
Medical terminologies are usually characterized into nomenclatures that are regarded as systematic listings of appropriate naming, including disease nomenclature that names and classifies illnesses, including the use of other relevant medical terms. On the other hand, classifications systems are different from medical terminologies in the sense that they group and categorize the terminologies in healthcare for specific uses, including establishing a uniform system for health reimbursement, to provide treatment outcome data for indexing as well as monitoring fraud, abuse, and other common compliance and regulatory problems. Consequently, medical terminology is the standard language used in the healthcare scope to ensure continuity of patient care, as it is important in communicating healthcare information among the practitioners.
A HIPAA code set revolves around the encoding of data elements. Some of these medical data elements include medical terms, concepts, diagnosis codes as well as procedure codes. Code sets are an important aspect of medical data and are usually a requirement in any administrative transaction as per the HIPAA regulations, which govern diagnoses, drugs as well as medical procedures. Additionally, these code sets create standardization of the electronic exchange of the patients’ very identifiable health information. HIPAA codes typically allow for the exchange of information electronically without any human being involved. Some of the approved HIPAA code sets include NDC (National Drug Codes), CDT (Code on Dental Procedures and Nomenclature), CPT (Current Procedure Terminology), and HCPCS (Health Care Common Procedure Coding System) as well as ICD 10 (International Classification of Disease).
The three chosen examples of systems classification include ICD-10, SNOMED CT, and CPT. The major functions of ICD-10 include tracking public health conditions in relation to complications as well as further anatomical location, helps in clinical decision-making, astute in shunning and identifying fraud and abuse, and measures the outcomes of the care given to the patients. However, the main function of the ICD-10 coding system is to offer accurate and updated procedure codes aimed at improving the cost of healthcare and promote fair reimbursement regulations. Currently, the ICD-10 codes are instrumental in helping healthcare practitioners identify patients who need immediate management of disease and ensure that they have access to a tailor-made management program that suits their needs. On the other hand, the SNOMED-CT’s main function is to encode the meanings of the terminologies used in the health information as well as supporting the efficient recording data with the aim of improving patient care across all margins.
It is important to note that the SNOMED-CT provides the foundation for the general terminology employed for electronic health records. Finally, the CPT codes are applicable when describing tests, surgeries, performing evaluations as well as any medically related procedure as per the HIPAA regulations, which indicated that a professional healthcare provider must perform the procedures. This code is extensive in the sense that it incorporates other codes for other numerous medical procedures with a mandate that they should only be done by a professional, without which it is considered unethical under the HIPAA policies.
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Part 3
Efficiency and accuracy of coded data can be ensured through managing coding audits and incorporating audit principles as well as reporting processes. Additionally, a coding compliance plan can also be beneficial in ensuring the efficiency and accuracy of coded data. A coding audit can be reflective, thereby including a review of claims, as well as performing an analysis of pre-billed claims. These types of audits are typically random but can also be targeted. The key processes involved in a coding audit include checking if the submitted codes are appropriately indicating the patient’s age, gender, and overall condition. Additionally, the capacity of the coded service to be billed is also checked in order to achieve a higher level of accuracy to avoid making any mistakes that could be detrimental to the whole system. The best way to manage coded audit is to create a plan. When creating a coding audit plan, it is important to establish an auditor and determine the frequency within which the audits will be done. Then focus on creating an accuracy goal as well as the audit size and the selected processes to be carried out during the audit.
In addition, a coded compliance plan can be very instrumental in determining the efficiency and accuracy of coded data. For instance, coding compliance connects to a compliance officer who reports to a compliance committee that can help ensure that coded data is accurate by pushing for frequent coding audits. The cording compliance plan also relies on written standards that rely on compliance-related communication. Equally, everything that happens in the medical field is usually written. These written standards ensure accuracy and credibility. Even though the coding compliance plan must ensure that all the written standards are met, it is also tasked with ensuring compliance-related communication occurs. This type of communication ensures that any organization knows its employee communication rate for easy implementation. The two policies are instrumental in ensuring that the coding is done ethically and transparently following the HIPAA guidelines.
References
Code Sets Overview. CMS. https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Code-Sets/index.html.
González Bernaldo de Quirós, F., Otero, C., & Luna, D. (2018). Terminology Services: Standard Terminologies to Control Health Vocabulary. Yearbook of medical informatics, 27(1), 227–233. https://doi.org/10.1055/s-0038-1641200
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