Health Information Management Technology with Online Access: An Applied Approach

816 Pages·1920·15.796 MB·English

by  Nanette B. Sayles

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Health a
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Technolhogy
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An Appliedht Approach
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Sixth Edition
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Copyright ©2020 by the American Health Information Management Association. All rights reserved. a ti
Except as permitted under the Copyright Act of 1976, no part of this publication may be reproduceodci, stored
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in a retrieval system, or transmitted, in any form or by any means, electronic, photocopying, recsording, or
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otherwise, without the prior written permission of AHIMA, 233 North Michigan Avenue, 21nst t Floor,
Chicago, Illinois 60601-5809 (http://www.ahima.org/reprint). e
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ISBN: 978-1-58426-720-1 a
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AHIMA Product No.: AB103118 a
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AHIMA Staff: o
Megan Grennan, Managing Editor m ati
Kimberly Wilson, Production Development Editor or
James Pinnick, Vice President, Content and Product Development nf
Rachel Schratz, MA, Assistant Editor h I
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Cover image: sollia ©Shutterstock n
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Limit of Liability/Disclaimer of Warranty: This book isri sold, as is, without warranty of any kind, either
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express or implied. While every precaution has beenm taken in the preparation of this book, the publisher
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and author assume no responsibility for errors oer omissions. Neither is any liability assumed for damages
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resulting from the use of the information or iyn tstructions contained herein. It is further stated that the
publisher and author are not responsible fobr any damage or loss to your data or your equipment that
results directly or indirectly from your u2s0e of this book.
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The websites listed in this book wer©e current and valid as of the date of publication. However, webpage
addresses and the information onht them may change at any time. The user is encouraged to perform his or
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her own general web searchesri to locate any site addresses listed here that are no longer valid.
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CPT® is a registered trademark of the American Medical Association. All other copyrights and trademarks
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Microsoft and Excel are registered trademarks of Microsoft Corporation. All other trademarks are the
property of their respective owners. This is an independent publication of the American Health Information
Management Association, and is neither affiliated with, nor an authorized sponsor of Microsoft Corporation.
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For more information, including updates, about AHIMA Press publications, visit http://www.ahima.org
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American Health Information Management Association
233 North Michigan Avenue, 21st Floor
Chicago, Illinois 60601-5809
ahima.org
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Health
Information
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An Applied Appror ach
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Sixth Edition n
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Volume© Editors
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Nayrinette B. Sayles, EdD, RHIA, CCS, CDIP, CHDA, CHPS, CPHI, CPHIMS, FAHIMA
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Leslie L. Gordon,
MS, RHIA, FAHIMA
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Brief Table of Contents
About the Volume Editors and Chapter Authors xxvi
Preface xxxii
Student and Instructor Online Resources xxxv
Acknowledgments xxxvi
Foreword xxxvii
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Part I Foundational Concepts ci 1
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Chapter 1 Health Information Management Profession nt 3
Nanette B. Sayles, EdD, RHIA, CCS, CDIP, CHDA, CHePS, CPHI, CPHIMS, FAHIMA
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Chapter 2 Healthcare Delivery Systems ag 21
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Kelly Miller, MA, RHIA a
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Chapter 3 Health Information Functions, Purpoons e, and Users 63
Nanette B. Sayles, EdD, RHIA, CCS, CaDtiIP, CHDA, CHPS, CPHI, CPHIMS, FAHIMA
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Part II Data Content, Structures and Sth aIndards 91
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Chapter 4 Health Record Content and Documentation 93
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Megan R. Brickner, aMSA, RHIA
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Chapter 5 Clinical Termimnologies, Classifications, and Code Systems 123
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Kathy Gianen angelo, MA, RHIA, CCS, CPHIMS, FAHIMA
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Chapter 6 Data My atnagement 153
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Dan0i ka E. Brinda, PhD, RHIA, CHPS, HCISPP
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Chapter 7 S2econdary Data Sources 197
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ht Marcia Y. Sharp, EdD, MBA, RHIA
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Part III I nforomp ation Protection: Access, Disclosure and Archival,
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Privacy and Security 221
Chapter 8 Health Law 223
Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA
Chapter 9 Data Privacy and Confidentiality 247
Laurie A. Rinehart-Thompson, JD, RHIA, CHP, FAHIMA
Chapter 10 Data Security 285
Megan R. Brickner, MSA, RHIA
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vi Brief Table of Contents
Part IV Informatics, Analytics, and Data Use 319
Chapter 11 Health Information Systems 321
Margret K. Amatayakul, MBA, RHIA, CHPS, CPEHR, FHIMSS
Chapter 12 Healthcare Information 363
Hertencia Bowe, EdD, MSA, RHIA, FAHIMA
Lynette M. Williamson, EdD, RHIA, CCS, CPC, FAHIMA
Chapter 13 Research and Data Analysis 391
Lynette M. Williamson, EdD, RHIA, CCS, CPC, FAHIMA
Chapter 14 Healthcare Statistics 429
Marjorie H. McNeill, PhD, RHIA, CCS, FAHIMA
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Part V Revenue Cycle Management and Compliance ati 471
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Chapter 15 Revenue Management and Reimbursement As 473
Morley L. Gordon, RHIT nt
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Chapter 16 Fraud and Abuse Compliance e 499
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Darline A. Foltz, RHIA, CHPS, CPC a
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Karen M. Lankisch, PhD, MHI, RHIA, CHDA, CaPC, CPPM
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Part VI Leadership ati 525
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Chapter 17 Management h I 527
Leslie L. Gordon, MS, RHIA, FalAtHIMA
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Chapter 18 Performance Improvemne nt 549
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Darcy Carter, DHSc, McHA, RHIA
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Miland N. Palmer, MePH, RHIA
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Chapter 19 Leadership e 583
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Leslie L. Gory dton, MS, RHIA, FAHIMA
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Chapter 20 Human 0R esources Management 607
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Valerie0 S. Prater, MBA, RHIT, FAHIMA
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Chapter 21 Eht thical Issues in Health Information Management 655
gMisty Hamilton, MBA, RHIT
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Appendix A Check YoCur Understanding Answer Key 679
Appendix B Glossary 715
Index 765
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Table of Contents
About the Volume Editors and Chapter Authors xxvi
Preface xxxii
Student and Instructor Online Resources xxxv
Acknowledgments xxxvi
Foreword xxxvii
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Part I Foundational Concepts ciati 1
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Chapter 1 Health Information Management Profession nt 3
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Early History of Health Information Management 4
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Hospital Standardization a 4
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Organization of the Association of Record Librarians a 4
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Approval of Formal Education and Certification Progrna ms 5
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Evolution of Practice ati 5
Traditional Practice m 6
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Information-Oriented Management Practice nf 6
The Future of HIM h I 7
Today’s Professional Organization ealt 8
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AHIMA Mission and Vision n 9
AHIMA Membership a 9
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AHIMA Structure and Operaetriion 10
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Association Leadership A 10
Engage e 10
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National Committye tes 10
House of Deleg0a tbes 12
State and Loca2l Associations 12
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Staff Structu2re 13
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Accredhti tation of Educational Programs 13
Certigfication and Registration Program 13
Felylriowship Program 14
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oAHIMA Support of Training and Education 14
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AHIMA Career Map 15
AHIMA Foundation 16
Commission on Accreditation for Health Informatics and Information
Management Education 16
Health Information Management Specialty Professional Organizations 16
Healthcare Information and Management Systems Society 17
Association for Healthcare Documentation Integrity 17
American Academy of Professional Coders 17
National Cancer Registrars Association 17
Real-World Case 1.1 18
Real-World Case 1.2 18
References 19
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viii Table of Contents
Chapter 2 Healthcare Delivery Systems 21
Healthcare Providers 22
Medical Practice 22
Physician Assistants 26
Nursing Practice 27
Allied Health Professions 27
Organization and Operation of Modern Hospitals 31
Types of Hospitals 33
Functionality 33
Location 33
Number of Beds 33
Specialization 33
Types of Ownership 34
Safety Net Hospitals n. 34
Critical Access Hospitals atio 34
Organization of Hospital Services ci 35
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Board of Directors s 35
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Medical Staff A 35
Administrative Staff nt 36
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Patient Care Services m 36
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Diagnostic Services g 37
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Rehabilitation Services n 37
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Ancillary Support Services M 37
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Other Types of Healthcare Services o 39
Managed Care Organizations ati 39
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Accountable Care Organizations or 40
Ambulatory Care nf 40
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Private Medical Practice alt 41
Medical Home e 41
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Hospital-Based Ambulatory Care Sernv ices 41
Community-Based Ambulatory Cacrae Services 41
Public Health Services eri 42
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Home Healthcare Services 42
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Voluntary Agencies e 43
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Subacute Care y t 44
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Long-Term Care 0 44
Long-Term Care i0n2 the Continuum of Care 44
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Delivery of Lo© ng-Term Care Services 44
Biomedical andht Technological Advances in Medicine 45
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Telehealth ri 45
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Electronipc Health Records and Health Data 46
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Artificial Intelligence 46
Policy Making and Healthcare Delivery 48
Healthy People 2020 48
The National Institutes of Health 50
National Academy of Medicine Reports 51
Centers for Disease Control and Prevention 51
Local, State, and Federal Policies 52
Patient-Centered Outcomes Research Institute 52
Modern Healthcare Delivery in the United States 54
Social Security Act of 1935 54
Public Law 89–97 of 1965 54
Public Law 92–603 of 1972 55
Utilization Review Act of 1977 55
Peer Review Improvement Act of 1982 55
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Table of Contents ix
Tax Equity and Fiscal Responsibility Act of 1982 56
Public Law 98–21 of 1983 56
Health Insurance Portability and Accountability Act of 1996 56
American Recovery and Reinvestment Act of 2009 56
Patient Protection and Affordable Care Act of 2010 57
Real World Case 2.1 58
Real-World Case 2.2 59
References 59
Chapter 3 Health Information Functions, Purpose, and Users 63
Purposes of the Health Record 64
Primary Purposes 64
Secondary Purposes 65
Formats of the Health Record n. 65
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Users of the Health Record ati 66
Individual Users ci 66
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Institutional Users s 67
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Overview of HIM Functions nt 68
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Medical Transcription and Voice Recognition m 69
Disclosure of Health Information ge 69
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Clinical Coding and Reimbursement n 70
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Record Storage and Retrieval Functions M 70
Master Patient Index on 70
Record Storage and Retrieval Functions in a Papaetir Environment 72
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Record Storage and Retrieval in an Electronicr Environment 81
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Identification Systems nf 84
Paper Health Record – Serial Numbering Sh yIstem 84
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Paper Health Record – Unit Numberineg System 85
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Paper Health Record – Serial-Unit nN umbering System 85
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Paper Health Record – Alphabeticc Filing System 85
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Electronic Health Record e 85
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Statistics and Research A 85
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Registries h 85
Birth and Death Certyi fitcates 85
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HIM Interdepartme0 ntal Relationships 86
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Virtual HIM 2 86
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HIM Informht ation Systems 87
Disclosugre of Health Information 87
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Charpt Tracking 87
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CCoding 87
Registries 87
Billing 87
Quality Improvement 87
Electronic Health Records 87
Personal Health Records 88
Real World Case 3.1 89
Real World Case 3.2 89
References 89
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x Table of Contents
Part II Data Content, Structures and Standards 91
Chapter 4 Health Record Content and Documentation 93
Role of Documentation 95
Documentation Standards 95
Standards 95
Medical Staff Bylaws 96
Accreditation 97
Joint Commission 99
State Statutes 100
Legal Health Record 100
General Documentation Guidelines 101
Documentation by Settings n. 103
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Inpatient Health Record ati 103
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Medical and Surgical o 104
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Ambulatory Surgery Record s 110
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Ancillary Departments nt 110
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Physician Office Record m 111
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Long-Term Care g 111
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Rehabilitation n 112
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Behavioral Health M 113
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Home Health o 113
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Federal and State Initiatives on Documentation m 115
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Health Information Media o 116
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Paper Health Record Documentation h I 116
Electronic Health Record Documentation alt 117
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Web-Based Document Imaging H 117
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Healthcare Providers in Documentatioan 118
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Physicians ri 118
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Nurses m 118
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Allied Health Professionals e 118
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HIM and Documentation y t 119
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HIM Roles 0 120
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Real-World Case 4.1 20 120
Real-World Case 4.2 © 121
References ht 121
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Chapter 5 Clinical oTperminologies, Classifications, and Code Systems 123
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History and Importance of Clinical Terminologies, Classifications, and Code Systems 124
Clinical Terminologies 126
SNOMED Clinical Terms 127
SNOMED CT Purpose and Use 127
SNOMED CT Content and Structure 127
Current Procedural Terminology 129
CPT Purpose and Use 129
CPT Content and Structure 131
Nursing Terminologies 131
Nursing Terminologies Purpose and Use 131
Nursing Terminologies Content and Structure 132
Classifications 133
International Classification of Diseases, Tenth Revision, Clinical Modification 133
ICD-10-CM Purpose and Use 133
ICD-10-CM Content and Structure 134
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