HIPAA for Health Care Professionals

184 Pages·2008·3.001 MB·English

by  Carole Krager, Dan Krager

HIPAA FOR HEALTH
CARE PROFESSIONALS
Dan Krager
Carole Krager, C.C.A.
Australia(cid:2)Brazil(cid:2)Japan(cid:2)Korea(cid:2)Mexico(cid:2)Singapore(cid:2)Spain(cid:2)UnitedKingdom(cid:2)UnitedStates
HIPAAforHealthCare (cid:2)2008Delmar,CengageLearning
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P r e f a c e
HIPAA for Health Care Professionals is a teaching/learning tool for both
students and members of the health care workforce. HIPAA (Health
Insurance Portability and Accountability Act) law mandates training of
all new employees and retraining on a routine basis for every employee
within health care. Training includes anyone who has possible contact
with protected health information. Beginning in 2003, many people were
concerned about what HIPAA would mean to the health care industry.
Some of these concerns were valid, and many others were quite extreme.
We hope to show the reasonableness of this law and how the health care
industry can comply and more fully protect individual health information.
In teaching a course in medical insurance and coding, the author
found HIPAA books that were written in haste. Most were technically
accuratebutdidnotcoverallareasofHIPAA.Othermorecomprehensive
texts were written with additions to include HIPAA law but were not
suitabletoexplainthecompletescopeofthelaw.Abasicunderstandingof
how health care is delivered today will contribute to greater understand-
ing.Asolidtextcapableofstimulatingin-depthlearningisneededwhena
health care professional faces critical compliance decisions.
Methods of Research
Instead of taking opinions from here and there, the authors researched
the government Web sites, the Federal Register, and actual advice
published by the Department of Health and Human Services concerning
howtounderstandtherules.Governmentwordingcanbequiteconfusing
socare was taken to define concepts as the governmentdefines them and
carefully present the intent of the law in everyday language.
Organization
Care was taken to study one element of HIPAA at a time to ensure the
reader’s understanding. HIPAA for Health Care Professionals is written
for easy reading. Knowledge of medical terminology is not required.
Coverage includes an introduction to HIPAA concepts, explanation of
privacyrule,transactionsandcodesets,securityrulesandtheirimpacton
iii
iv Preface
theworkplace,andadiscussionofmythssurroundingHIPAA.Formsand
resourcesthatcanbeusedintheworkplaceareincludedintheappendix.
Features
Each chapter contains the following:
l Chapter objectives and a key term list to help the reader focus their
learning
l ThinkAboutItfeaturesfoundatthebeginningofeachchapteraswell
as throughout the chapter stimulate reflection about concepts
discussed.Thequestionsposedcanbediscussedpriorto readingand
then addressed later to see if first impressions were correct.
l True Stories and Scenarios illustrate actual real-life happenings and
emphasize the importance of HIPAA compliance.
l ReviewQuestionsfoundattheendofchapterallowthereadertocheck
their understanding of chapter concepts.
Also available:
WebTutor on Web CT to Accompany HIPAA for Health Care Professionals
ISBN: 1418080551
WebTutoronBlackboardtoAccompanyHIPAAforHealthCareProfessionals
ISBN: 141808056X
Designed tocomplementthebook,WebTutor isaWeb-basedteaching
andlearningaidthatreinforcesandclarifiescomplexconcepts.Thisvaluable
resource includes key concepts, Web links, discussion questions, glossary,
andadditionalquizzes.TheWebCTandBlackboardplatformsalsoprovide
rich communication tools to instructors and students, including a course
calendar, chat, e-mail, and threaded discussions.
Instructor Resources
An Electronic Classroom Manager is available to instructors.
ISBN 1-4180-8054-3
Included in the package:
l Instructor’s Manual,including answersto ThinkAbout Itquestions
and Review Questions, and ideas on how material can be used in
professional training scenarios
l 100 PowerPoint slides to assist in classroom presentations and
lectures
l Computerized Test Bank containing 250 questions; allows users to
generate tests with a few clicks of a button!
A b o u t t h e A u t h o r s
Dan Krager is Manager of Information Systems, Richland Memorial
Hospital, Olney, IL; HIPAA Officer for Richland Memorial Hospital;
HIPAA Security Officer for Richland Memorial Hospital; Bachelor of
Science,WheatonCollege,Wheaton,IllinoisCertifiedNetworkEngineer
inNovellSystems,Ciscosystems,andLinuxtraining;andhasover15years
experience in computer and network applications for hospital settings.
As HIPAA Officer and HIPAA Security Officer, Dan enabled Richland
Memorial Hospital to move toward compliance. He worked closely with
the Illinois Hospital Association to build a statewide infrastructure that
enables health care organizations to interconnect electronically.
Carole H. Krager is Instructor at Olney Central College campus of
Illinois Eastern Community College, Olney, IL in the Business Depart-
ment, teaching Medical Insurance and Coding; Bachelor of Science,
Wheaton College, Wheaton, IL; experienced in clinic billing; trained in
diagnosis coding at Triton College, River Grove, IL; experienced in out-
patient hospital coding; member of the American Health Information
Management Association and Certified Coding Assistant (CCA) profi-
ciency. Carole has been an educator for more than 25 years and has
successfully communicated in an easy-to-understand manner. She has
beentrainedinteachingstudentswholearnoutsidethenorm.Experience
with billing and coding enabled her to understand the inner workings of
both physician and hospital offices.
v
A c k n o w l e d g e m e n t s
We wish to thank members of Richland (IL) Memorial Hospital for their
assistance. We have listened to how they moved to HIPAA compliance and
found some pitfalls. We hope you will avoid those pitfalls through full
understandingoftheHIPAArulings.ThespecificfriendsareLezlieLambird,
Medical Records Department; Tom Stein, Pharmacy Department; Julie
Struble, Admitting Department; Lana Royse, Quality Assurance Improve-
ment; Randy Bishop, Diagnostic Imaging Department; Bruce Maxwell,
Emergency Department; Jack Fleeharty, Ambulance Department; and Bob
Gammon, Food Service Department.
We would like to send a special thank you to the reviewers of our
manuscript. Their input was invaluable.
Christa Bartlett, CMA-CPC
Assistant Professor
University of Alaska Fairbanks/Tanana Valley Campus
Fairbanks, Alaska
Mark Forquer, BS, Ed, NCMA
Medical Assistant Instructor
Advanced Career Training
Jacksonville, Florida
Carolyn H. Greene, BS, MBA, RHE
Academic Dean, School of Health Sciences
Program Director Health Services Management
Virginia College at Birmingham
Birmingham, Alabama
Barbara Hogg, MLT, RN, BSN
Director of Distance Learning
South Arkansas Community College
El Dorado, Arizona
Stacey May, CST
Program Director/Instructor of Surgical Technology
and Surgical Assisting South Plains College
Lubbock, Texas
vi
Acknowledgements vii
We have endeavored to thoroughly cover the areas of HIPAA that
have brought the most misunderstanding. Certainly there are gray areas
that health care professionalswill encounter. If we can be of assistance to
clarify and offer a carefully considered opinion, we certainly welcome the
opportunity. Our e-mail address is [email protected] and our mailing
address is 4730 N Wilder Road, Olney, IL 62450.
C o n t e n t s
Preface
iii
About the Authors
v
Acknowledgements
vi
Chapter 1
Introduction to HIPAA 1
Introduction 2
How the Rules Came into Existence 3
Titles of HIPAA Law 5
Title I: Health Insurance Access, Portability, and Renewal 5
Title II: Preventing Health Care Fraud and Abuse; Administrative
Simplification; Medical Liability Reform 5
Title IV: Group Health Plan Requirements 7
Other Titles in HIPAA 7
HIPAA: An Organizational and Business Challenge 8
Who Is a “Covered Entity?” 10
The HIPAA Officer 11
Summary 12
Review Questions 24
References 25
Chapter 2
Privacy Issues Explained 26
Introduction 27
To Whom Does Title II Apply? 27
What Is Protected Health Information? 28
Authorization versus Consent 30
Concerns about Protected Health Information and Possible
Disclosures 32
Required Disclosures 32
viii
contents ix
Permitted Use and Disclosure without Authorization 33
For Individual Access 33
For Treatment, Payment, and Health Care Operations 34
When Permission to Disclose is Received 35
When Incidental 36
For Public Interest or to Benefit the Public 36
For Research 38
Permitted Use and Disclosure with Authorization 38
Disclosure of Psychotherapy Notes 38
Disclosure for Marketing Purposes 39
Disclosure for Directory Purposes 40
Limiting Uses and Disclosures 40
Minimum Necessary Uses 41
Business Associates under the Privacy Rule 42
Training of the Public and Workforce 43
Amending Protected Health Information 44
Enforcement Guidelines 45
Civil Penalties under HIPAA 46
Criminal Penalties under HIPAA 47
What the HIPAA Privacy Rule Covers 49
Summary 50
Review Questions 51
References 52
Chapter 3
Transactions and Code Sets 54
Introduction 55
Purpose of Transaction Standards 56
Designated Code Sets 59
Diagnosis Codes 60
Inpatient Procedure Codes 61
Outpatient Procedure Codes 61
Dental Procedures 62
Drug Codes 62
Nonmedical Code Sets 63
ASC X12 Nomenclature 64
Data Overview 64
Architecture 65
Use of Loops 68
Sample of EDI Claim Data (UB-04, Hospital Billing Form) 69
Limitations of Electronic Claims 74