Health Information Management Technology: An Applied Approach

1338 Pages·2012·47.572 MB·English

by  Nanette B. Sayles

i
Health Information
Management Technology
An Applied Approach
Fourth Edition
Nanette B. Sayles, EdD, RHIA,
CHPS, CCS, CPHIMS, FAHIMA
Editor
AHIMA_HIT2012_ch00fm.indd 1 9/24/12 5:13 PM
Copyright ©2013 by the American Health Information Management Association. All
rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, photocopying, recording,
or otherwise, without the prior written permission of the publisher.
ISBN: 978-1-58426-352-7
AHIMA Product No.: AB103112
AHIMA Staff:
Jessica Block, MA, Assistant Editor
Claire Blondeau, MBA, Managing Editor
June E. Bronnert, RHIA, CCS, CCS-P
Jill S. Clark, MBA, RHIA
Adrienne Cook, JD, Developmental Editor
Kathryn A. DeVault, RHIA, CCS
Angela K. Dinh, MHA, RHIA, CHPS
Melanie A. Endicott, MBA, RHIA, CCS, CCS-P
Katie Greenock, MS, Editorial and Production Coordinator
Karen M. Kostick, RHIT, CCS, CCS-P
Jason O. Malley, Director, Creative Content Development
Diana M. Warner, MS, RHIA, CHPS
Lou Ann Wiedemann, MS, RHIA
All information contained within this book, including websites and regulatory
information, was current and valid as of the date of publication. However, web page
addresses and the information on them may change or disappear at any time and for
any number of reasons. The user is encouraged to perform his or her own general web
searches to locate information associated with addresses that are no longer valid.
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this book, registered trademarks of the companies referenced in this book, or neither.
This book is sold, as is, without warranty of any kind, either express or implied. While
every precaution has been taken in the preparation of this book, the publisher and author
assume no responsibility for errors or omissions. Neither is any liability assumed for
damages resulting from the use of the information or instructions contained herein. It is
further stated that the publisher and author are not responsible for any damage or loss to
your data or your equipment that results directly or indirectly from your use of this book.
American Health Information Management Association
233 North Michigan Avenue, 21st Floor
Chicago, Illinois 60601-5809
ahima.org
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Contents
About the Editor and Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xli
Part 1 Healthcare Data Management
Chapter 1 Introduction to the HIM Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nanette B. Sayles, EdD, RHIA, CCS, CHPS, CPHIMS, FAHIMA
Chapter 2 Purpose and Function of the Health Record. . . . . . . . . . . . . . . . . . . . . . 31
Cheryl V. Homan, MBA, RHIA
Chapter 3 Content and Structure of the Health Record. . . . . . . . . . . . . . . . . . . . . . 67
Bonnie J. Petterson, PhD, RHIA
Chapter 4 Healthcare Data Sets and Standards. . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Kathy Giannangelo, MA, RHIA, CCS, CPHIMS, FAHIMA
Chapter 5 Clinical Vocabularies and Classification Systems . . . . . . . . . . . . . . . . 179
Karen S. Scott, MEd, RHIA, CCS-P, CPC
Chapter 6 Reimbursement Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Anita C. Hazelwood, MLS, RHIA, FAHIMA
Carol A. Venable, MPH, RHIA, FAHIMA
Chapter 7 Health Information Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
Lisa A. Cerrato, MS, RHIA and Jane Roberts, MS, RHIA
Part 2 Health Statistics, Biomedical Research,
and Quality Management
Chapter 8 Secondary Data Sources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
Marcia Sharp, EdD, RHIA
Chapter 9 Healthcare Statistics and Productivity . . . . . . . . . . . . . . . . . . . . . . . . . 469
Loretta A. Horton, MEd, RHIA
Chapter 10 Clinical Quality Performance Improvement and Management . . . . . . 559
Chris R. Elliott, MS, RHIA
iii
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iv Contents
Part 3 Health Services Organization and Delivery
Chapter 11 Healthcare Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 637
Donald W. Kellogg, PhD, RHIA, CPEHR
Chapter 12 Ethical Issues in Health Information Management. . . . . . . . . . . . . . . . 715
Laurinda B. Harman, PhD, RHIA, FAHIMA
Appendix A: Ethical Standards for Clinical Documentation
Improvement (CDI) Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 765
Chapter 13 Legal Issues in Health Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . 771
Laurie A. Rinehart-Thompson, JD, RHIA, CHP
Part 4 Information Technology and Systems
Chapter 14 Fundamentals of Electronic Information Systems . . . . . . . . . . . . . . . . 845
Martin J. Smith, MEd, RHIT, CCA
Chapter 15 Introduction to Electronic Health Information Systems. . . . . . . . . . . . 905
Nanette B. Sayles, EdD, RHIA, CCS, CHPS, CPHIMS, FAHIMA
Chapter 16 Electronic Health Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 947
Margret K. Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR, FHIMSS
Chapter 17 Information Security. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1021
Sheila Carlon, PhD, RHIA, FAHIMA, CHPS
Part 5 Organizational Resources
Chapter 18 Principles of Organization and Work Planning. . . . . . . . . . . . . . . . . . 1073
Donald W. Kellogg, PhD, RHIA, CPEHR
Chapter 19 Envisioning the Future of the Health Information
Management Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1139
Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS,
2011 President of AHIMA
Appendix A Sample HIM Position Descriptions . . . . . . . . . . . . . . . . . . . . . . . . . . 1155
Appendix B Sample Notice of Health Information Practices. . . . . . . . . . . . . . . . . 1157
Appendix C Check Your Understanding Key . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1161
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1177
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1259
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Detailed Table of Contents
About the Editor and Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xli
Part 1 Healthcare Data Management
Chapter 1 Introduction to the HIM Profession . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Theory into Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Early History of Health Information Management. . . . . . . . . . . . . . . . . . 6
Hospital Standardization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Organization of the Association of Record Librarians. . . . . . . . . . . . 7
Approval of Formal Education and Certification Programs. . . . . . . . 7
Evolution of Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Traditional Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Information-Oriented Management Practice . . . . . . . . . . . . . . . . . . 10
Visioning the Future of HIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
From Traditional Roles to New Opportunities. . . . . . . . . . . . . . . . . 12
Today’s Professional Organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Mission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Structure and Operation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Health Information Management Specialty Professional
Organizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Healthcare Information and Management Systems Society . . . . . . 24
Association for Healthcare Documentation Integrity. . . . . . . . . . . . 25
American Academy of Professional Coders. . . . . . . . . . . . . . . . . . . 25
National Cancer Registrars Association. . . . . . . . . . . . . . . . . . . . . . 25
American Recovery and Reinvestment Act of 2009—
Community College Consortia to Educate Health
Information Technology Professionals . . . . . . . . . . . . . . . . . . . . 25
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Real-World Case. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
v
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vi Detailed Table of Contents
Chapter 2 Purpose and Function of the Health Record . . . . . . . . . . . . . . . . . . . 31
Introduction............................................... 32
Theory into Practice ........................................ 33
Purposes of the Health Record ................................ 35
Primary Purposes ....................................... 35
Secondary Purposes ..................................... 36
Users of the Health Record................................... 38
Individual Users........................................ 39
Institutional Users ...................................... 43
Functions of the Health Record ............................... 47
Storage of Patient Care Documentation...................... 47
Guidance in Clinical Problem Solving....................... 60
Real-World Case #1 ........................................ 63
Summary................................................. 64
Real-World Case #2 ........................................ 64
References................................................ 65
Additional Resources ....................................... 66
Chapter 3 Content and Structure of the Health Record . . . . . . . . . . . . . . . . . . . 67
Introduction............................................... 68
Theory into Practice ........................................ 69
Documentation Standards.................................... 70
Types of Standards...................................... 70
Standards Organizations.................................. 71
Acute Care Health Record Documentation ...................... 77
Basic Acute Care Content ................................ 77
Clinical Data........................................... 78
Administrative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Consents, Authorizations, and Acknowledgments............. 102
Specialized Health Record Documentation ..................... 106
Emergency Care Documentation .......................... 106
Ambulatory Care Documentation ......................... 107
Ambulatory Surgical Care Documentation .................. 110
Long-term Care Documentation........................... 111
Home Healthcare Documentation ......................... 113
Hospice Care Documentation............................. 114
Behavioral Healthcare Documentation ..................... 114
Rehabilitation Services Documentation..................... 116
Documentation of Services Provided in Correctional
Facilities........................................... 117
End-stage Renal Disease Service Documentation............. 117
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Detailed Table of Contents vii
Principles and Practices of Health Record Documentation ......... 119
Basic Documentation Principles .......................... 119
Clinical Documentation Improvement...................... 120
Format of the Health Record................................. 125
Paper-Based Health Records ............................. 125
Electronic Health Records ............................... 128
Hybrid Records ....................................... 130
Personal Health Records ................................ 131
Real-World Case.......................................... 134
Summary................................................ 135
References............................................... 136
Additional Resources ...................................... 136
Chapter 4 Healthcare Data Sets and Standards . . . . . . . . . . . . . . . . . . . . . . . . . 139
Introduction.............................................. 140
History of Healthcare Data Collection...................... 141
Data Sets in the Electronic Environment . . . . . . . . . . . . . . . . . . . . 142
Developing Standardized Data Sets and Standards ............ 142
Theory into Practice ....................................... 143
Data Sets................................................ 145
Definition of Data Set................................... 145
Importance and Use of Data Sets.......................... 145
Types of Data Sets ........................................ 146
Data Sets Required or Recommended by the Federal
Government ........................................ 146
Data Sets for Interoperable Electronic Information Exchange ... 156
Standards for Electronic Data and Electronic Data Interchange ..... 159
Definition of Data Standard for Electronic Data Exchange...... 160
Data Needs in an Electronic Environment................... 160
Benefits of Data Exchange Standards ...................... 161
American Recovery and Reinvestment Act .................. 162
Standards Development, Coordination, Testing, and
Harmonization ...................................... 163
Types of Standards..................................... 167
Emerging Health Information Standards ....................... 172
Extensible Markup Language (XML) ...................... 172
Metadata Standards .................................... 172
Summary................................................ 173
Role of HIM Professional................................... 173
Real-World Case.......................................... 173
References............................................... 175
Additional Resources ...................................... 177
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viii Detailed Table of Contents
Chapter 5 Clinical Vocabularies and Classification Systems . . . . . . . . . . . . . . 179
Introduction.............................................. 180
Theory into Practice ....................................... 180
History and Importance of Clinical Vocabularies................. 181
Clinical Vocabularies, Classifications, and Nomenclatures ......... 181
International Classification of Diseases, Ninth Revision,
Clinical Modification................................. 182
International Classification of Diseases, Tenth Revision,
Clinical Modification................................. 190
International Classification of Diseases, Tenth Revision,
Procedure Coding System ............................. 193
Implementation of ICD-10 in the United States............... 194
ICD-9-CM to ICD-10-CM Transition Issues................. 195
International Classification of Functioning,
Disability, and Health (ICF)............................ 196
International Classification of Diseases for Oncology,
Third Edition ....................................... 197
Healthcare Common Procedure Coding System .............. 199
Current Procedural Terminology, Version 4.................. 201
Systematized Nomenclature of Medicine ................... 205
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision........................... 208
Nursing Vocabularies ................................... 210
The Coding Process ....................................... 212
Standards of Ethical Coding.............................. 212
Elements of Coding Quality.............................. 213
Coding Policies and Procedures........................... 214
Steps in the Coding Process.............................. 214
Quality Assessment for the Coding Process.................. 215
Coding Technology........................................ 217
Encoders............................................. 217
Unifying Clinical Vocabularies............................... 221
National Library of Medicine UMLS Project ................ 221
Development of the Nosologist Role....................... 222
Real-world Case .......................................... 223
Summary................................................ 224
References............................................... 225
Additional Resources ...................................... 226
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Detailed Table of Contents ix
Chapter 6 Reimbursement Methodologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Introduction.............................................. 230
Theory into Practice ....................................... 231
History of Healthcare Reimbursement in the United States......... 231
Pre-Medicare/Medicaid Campaigns for National
Health Insurance .................................... 231
Medicare/Medicaid Programs ............................ 232
Cost Management...................................... 233
Development of Prepaid Health Plans ...................... 233
Healthcare Reimbursement Systems........................... 237
Commercial Insurance .................................. 237
Not-for-Profit and For-Profit Healthcare Plans ............... 238
Blue Cross and Blue Shield Plans ......................... 238
Government-Sponsored Healthcare Programs................ 239
Managed Care ........................................ 254
Healthcare Reimbursement Methodologies ..................... 260
Fee-for-Service Reimbursement Methodologies .............. 261
Episode-of-Care Reimbursement Methodologies ............. 262
Capitation............................................ 263
Global Payment ....................................... 263
Prospective Payment ................................... 264
Medicare Prospective Payment Systems........................ 266
Medicare Acute Inpatient Prospective Payment System (IPPS)... 266
Resource-Based Relative Value Scale (RBRVS) System........ 271
Skilled Nursing Facility Prospective Payment System ......... 273
Outpatient Prospective Payment System .................... 274
Ambulatory Surgery Center Prospective Payment
System (ASC PPS)................................... 277
Home Health Prospective Payment System (HH PPS) ......... 278
Ambulance Fee Schedule................................ 280
Inpatient Rehabilitation Facility (IRF) Prospective
Payment System..................................... 281
Long-Term Care Hospital (LTCH) Prospective
Payment System..................................... 282
Inpatient Psychiatric Facilities (IPFs) Prospective
Payment System..................................... 284
Processing of Reimbursement Claims ......................... 288
Coordination of Benefits ................................ 288
Submission of Claims................................... 288
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