Objective 3.02
I.
II.
III.
IV.
V.
Analyze information
Abstract and code patient information
1.
Diagnosis codes
2.
Procedure codes
Document information
1.
Obtain and record patient information
2.
Transcribe health information
3.
Complete and process insurance forms
4.
Follow legal guidelines for documents
Communicate information
1.
File records
2.
Use technology
3.
Schedule appointments
4.
Complete medical records forms
5.
Maintain accounting records
Manage health information systems
3.02 Understand health informatics
Directions: Record notes and class discussion in your own words. Compare the ICD9-CM and CPT codes as you view the PowerPoint presentation.
Health Informatics
Health
Informatics 1
Management Duties
Technical Duties
1
2
2
3
3
4
4
Health 1
Informatics
Professionals 2
3
4
5
Analyze patient 1
information
2
3
4
Abstract and
code patient
information
ICD-9-CM Coding
1
2
3
http://icd9cm.chrisendres.com/
http://www.findacode.com/search/search.php
CPT Coding
3.02 What’s the Main Term?
Directions: Using the ICD-9-CM for reference, identify and underline the main term in
each diagnosis listed below.
1.
Open fracture, maxilla
2.
Congenital diaphragmatic hernia
3.
Diaper rash
4.
Dysplasia of the cervix
5.
Sleep apnea
6.
Intracranial abscess
7.
Congestive heart failure
8.
Acute cystitis
9.
Chronic maxillary sinusitis
10.
Impacted feces
11.
Upper respiratory infection
12.
Irritability of the stomach
13.
Elevated blood pressure
14.
Nontraumatic rupture of Achilles tendon
15.
Diabetic cataract
16.
Cushing’s Syndrome
17.
Vitamin B12 deficiency
18.
Trench mouth
19.
Webbed toes
20.
Intrinsic asthma in status asthmaticus
3.02 ICD-9-CM Coding
Directions: Use the ICD-9-CM Code book to assign the correct ICD-9-CM codes for the
following diagnoses. Follow the Basic Steps of ICD-9-CM Coding.
1.
Allergic diarrhea __________
2.
Cholesterolosis of gallbladder __________
3.
Urethral chancre __________
4.
Cystic fibrosis __________
5.
Congestive rheumatic heart failure __________
6.
Viral meningitis __________
7.
Cleft lip and palate __________
8.
Pancytopenia __________
9.
Infantile cerebral palsy __________
10.
Anal fistula __________
11.
Acne vulgaris __________
12.
Dermatophytosis of the foot __________
13.
Hiatal hernia with obstruction and gangrene __________
14.
Mitral valve insufficiency __________
15.
Monocytic leukocytosis __________
16.
Lung mass __________
17.
Prolapse of the bladder, female __________
18.
Rupture of the gallbladder __________
19.
Venereal warts __________
20.
Gouty arthritis __________
3.02 CPT Coding
Directions: Use the CPT Code book to assign the correct CPT code for the following
procedure/service. Follow the Basic Steps of CPT Coding.
1.
Arthrography of the knee, supervision and interpretation __________
2.
Lipid panel blood test __________
3.
Breast abscess, incision and drainage __________
4.
Pneumocentesis __________
5.
Closed reduction of closed fracture, clavicle, without manipulation __________
6.
Influenza vaccine, age 3 years old (preservative free) __________
7.
Bacteria culture, urine __________
8.
Stool for occult blood __________
9.
X-ray pelvis, 4 views __________
10.
Bilateral screening mammography ____________________
11.
Diagnostic arthroscopy, right wrist, with synovial biopsy __________
12.
Laparoscopic cholecystectomy with cholangiography __________
13.
Anesthesia services for hernia repair in the lower abdomen __________
14.
Dilation of cervical canal __________
15.
Molar pregnancy excision __________
16.
Electrosurgical removal, 12 skin tags __________
17.
Magnetic resonance imaging (MRI), lumbar spine with contrast __________
18.
Needle core biopsy of lung __________
19.
Destruction of 8 warts __________
20.
Repair of complex, open wound of scalp; 2.8 cm __________
3.02 Understand health informatics II
Directions: Record notes and class discussion in your own words.
Document
information
Communicate
information
Manage health
information
systems
Career Responsibilities
Class Discussion
3.02 Using Medical Abbreviations
Directions: Translate the following patient scenario and rewrite the scenario using the
definition of the abbreviation. Underline the definition.
Katie was admitted to the ED with complaints of FUO, N/V, and SOB. She had had
nothing po because the sx became worse pc. A CBC, UA, and BS were ordered. An
intravenous line was started and she was made NPO. Her TPR was normal but her P
had increased. After a few hours, it was determined that she could be OOB and the
order for BR was discontinued. She was placed on cl liq and received more than gtts
for lunch. Her initial Dx of R/O salmonella was amended as she tolerated the liquids.
When all lab work returned WNL, she was discharged. On the way out of the ED, she
had to complete the paperwork with her DOB and was given a Rx for nausea.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3.02 Medical Abbreviations
a
ac
ad lib
ax
BR
BS
BSE
CBC
cl liq
DNR
DOA
DOB
Dx, dx
ED
FUO
gtt
NPO
N/V, N&V
p
P
OOB
pc
po
R
R/O
ROM
Rx
SOB
Sx
T, temp
TPR
UA, U/A
WNL
before
before meals
as desired
axillary
bedrest
blood sugar
breast self-exam
complete blood count
clear liquids
do not resuscitate
dead on arrival
date of birth
diagnosis
emergency department
fever of unknown origin
drop
nothing by mouth
nausea and vomiting
after
pulse
out of bed
after meals
by mouth
respiration
rule out
range of motion
treatment
shortness of breath
symptom
temperature
temperature, pulse, respiration
urinalysis
within normal limits
3.02 Medical Abbreviations Quiz
Directions: Write the meaning of the following abbreviations:
1. ad lib
2. ax
3. ac
4. BSE
5. DNR
6. DOA
7. R
8. ROM
9. T
10. UA
11. FUO
12. P
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Directions: Write the abbreviation for the following medical terms:
1. bedrest
____________________________
2. blood sugar
____________________________
3. complete blood count _______________________
4. clear liquids
____________________________
5. date of birth
____________________________
6. diagnosis
____________________________
7. emergency department _______________________
8. drop
____________________________
9. nothing by mouth____________________________
10. nausea and vomiting _______________________
11. out of bed
____________________________
12. after meals
____________________________
13. by mouth
____________________________
14. respiration
____________________________
15. rule out
____________________________
16. range of motion ____________________________
17. treatment
____________________________
18. shortness of breath _________________________
19. symptom
____________________________
20. temperature
____________________________
21. within normal limits _________________________
3.02 Proofreading Exercise
Directions: In the record below, circle misspelled words and identify missing words.
Underline the misspelled words and write the corrected and missing words in the
appropriate blanks. Consult medical and English dictionaries as necessary.
1. The labratory testing of blood, urine, and
1. ________________________
2. other body fliuds and waste products plays a 2. ________________________
3. miner roll in modern diagnostic medicine.
3. ________________________
4. The number of availabel tests increases
4. ________________________
5. almost daily, and the range of diseses and
5. ________________________
6. conditions able to be tested in labratory
6. ________________________
7. studys continually broadens. Some mention 7. ________________________
8. of labratory test results appears frequently
8. ________________________
9. in history, in physical examintion reports
9. ________________________
10. and nearly always in hospital discharge
10. _______________________
11. summarys. Accordingly the medical
11. _______________________
12. transcirptionist must be familiar with the
12. _______________________
13. general conceps of laboratory medicine as 13. _______________________
14. well as with pecific tests. Diagnostic
14. _______________________
15. labratory procedures may be called tests,
15. _______________________
16. studies, or simply work (“lab studies, “ “lab 16. _______________________
17. word”). Phisicians may report that they
17. _______________________
18. ordered, got, ran, did, or (in the case of
18. _______________________
19. blood work) drew a test.
19. _______________________
20. Crohn’s disease is a chronic dysorder
20. _______________________
21. which consists of inflamation of the
21. _______________________
22. gastrointestinal track. It is most commonly 22. _______________________
23. inflamation of the terminal ilium. The
23. _______________________
24. exact cause is unknown, but possible
24. _______________________
25. causes are allerges, imune
25. _______________________
26. disorders, and infections. Labratory tests
26 _______________________
27. have not detected any bacteria or virus
27. _______________________
28. responsable for causing Crohn’s disease. 28. ________________________
29. The patient experiences cramping,
29. _______________________
30. abdominal pain, nausea, diarrhea,
30. _______________________
31. abdominal tenderness, and weekness.
31. _______________________
32. Patience may be given intervenous fluids
32. _______________________
33. to provide nutrition while resting the bile.
33. _______________________
34. Some patients require surgery if the bile
34. _______________________
35. perforates,obstructs, or if there is
35. _______________________
36. massive hemorhage.
36. _______________________
3.02 Medical Insurance Key Terms
Key Term
abstracting
claims attachment
coding
ICD-9-CM
CPTa
Definition
Student Notes
CMS
explanation of
benefits (EOB)
health insurance
claim form (CMS1500)
medical necessity
preauthorization
remittance advice
3.02 Case Study –
Insurance Claim Forms Completion
Complete a CMS-1500 claim form for each patient using their patient information form,
copies of their insurance cards, charts and ledger cards.
Use the information on the Patient Registration Form Handout and Documentation on
Patient’s Medical Record to complete the claims for patients in a general surgeon’s
office and family practice.
Physician Information
Group:
Family Medicine and General Surgery Specialist, PA
2222 Staton Road
Anyville, NC 27834
Federal Tax ID #: 56-412250
Physicians & Physician Insurance (PIN)#:
S. W. Jones, MD
Medicaid #: 8974585
Medicare #: 21022A
B. D. Thomas, MD
Medicaid #: 8921333
Medicare #: 22552A
Hospital:
Generic Hospital
P.O. Box 6028
Anyville, NC 27000-6028
Insurance programs that the office participates in are Medicare, Medicaid, BCBS.
3.02
Patient Registration Form
Name: Jean Smith
Social Security No: 244-44-4444
Street Address: 452 Farm Blvd
City, State, Zip: Anyville, NC 27828
DOB: 1-5-40
Phone: (H) (252) 753-5300
(W): (252) 753-5266
Occupation/Employer: Perdue
Sex: Female
Physician: Jones
Spouse’s Name: John Smith
Status: Married
Emergency Contact: Jane Smith
Emergency Contact Phone: 753-1111
(Other than Spouse)
Insurance Plan:
Policy ID#:
Group #:
Prudential
YPP5689XX3
37500
Policyholder Name:
Birthdate:
Relationship:
Amanda Dixon
1-5-40
Self
Secondary
Policy:
Policy #:
Group #:
Policyholder
Name:
Birthdate:
Relationship:
Assignment of Insurance Benefits
I hereby authorize direct payment of surgical/medical benefits to Dr. ___________________ for services rendered by
him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered
by my insurance.
Authorization to Release Information
I hereby authorize Dr. ________________________ to release any medical or incidental information that may be necessary
for either medical care or in processing applications for financial benefit.
Medicare-Medicaid
I certify that the information given by me in applying for payment is correct. I authorize release of all records on request. I
request that payment of authorized benefits be made on my behalf.
A photocopy of these assignments shall be valid as the original.
PATIENT SIGNATURE:
Amanda Dixon
DATE: 01-01-06
PARENT/GUARDIAN (please print): _____________________________SIGNATURE: _________________________
3.02 Documentation on Patient’s Medical Record
Date
Jean Smith
10-15-07S:
O:
Account # 4XXX
HISTORY & PHYSICAL
Patient still having abnormal bleeding with the flow getting heavier each month. LMP
10-1-07, lasting 6 days, heavy with large clots. Heavy periods for the past year with
increased pain and clots. Hemoglobin on last visit was 11.2
Uterus soft with fibroid uteri. Uterus increased in size. Also has cystourethrocele
without a uterine prolapse.
Hemoglobin 9.0.
A:
Menorrhagia, severe.
Anemia.
Fibroids, leiomyomata uteri.
Cystourethrocele without uterine prolapse.
P:
Schedule TAH-BSO, Marshall-Marchetti in 2 weeks.
S. w. Jones, MD
10-16-07
Scheduled TAH-BSO, Marshall-Marchetti for 11-4-07. LT/RN
11-4-07
Performed total abdominal hysterectomy with bilateral salpingo-oophorectomy with
Marshall-Marchetti for the cystourethrocele.
S. W. Jones, MD
11-5-07
Patient discharged from the hospital to return to the office in three weeks for a recheck.
S. W. Jones, MD
3.02 Filing Records
Alphabetic Filing
 All personal names are transposed so that the last name is the primary indexing
unit, first name second and middle name or initial is the third unit.
 April Smith
Smith, April
 Jesse W. Brown
Brown, Jesse W.
 If filing identical names, use the city and street names to place in alphabetical
sequence
 Don S. Clay, Asheboro, N. C.
Clay, Don S. Asheboro
 Don S. Clay, Raleigh , N. C.
Clay, Don S. Raleigh
 Names with prefixes are filed disregarding punctuation and spacing within the
surname
 Rena de la Santos
de la Santos, Rena
 Amee La Croix
La Crois, Amee
 David M. McArthur
McArthur, David M.
 Abbreviated names are files as though the names were spelled out.
 Chas. Malley
Malley, Charles
 Charles L. Malley
Malley, Charles L.
 Professional titles and degrees are placed at the end of the name and enclosed
in parentheses.
 Organizations and Businesses in order they are written
American, Red, Cross
 Exception: If Owner's name is name of business, then follow name rules
The T.S. Eliot Company is filed as Eliot, T., S., Company
 Hyphenated names are considered as one unit
 After indexing, follow strict alphabetical order, use as many letters as needed to
file
 Nothing comes before something
 Numbers in a name are indexed as though they were spelled out
Numeric Filing
 Cross indexing (referencing) is required
 Patient names are indexed as for alpha filing
 Agency numbering usually runs in order, and a record is kept of which numbers
have been assigned.
 When patient comes to agency, alpha cross index is checked to locate patient's
file number
 Numbers go in order from small to large
 If zero falls before other numbers, the zero is disregarded when filing
 Many systems use the same terminal (last) digit for certain shelves or drawers if so - check the last digit and then put all the same last digits together
3.02
Alphabetic Filing
Directions: Index each patient’s name in the space provided. Put the names in
alphabetic order in the space provided.
Indexed Names
Alphabetic Names
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Mary Childers
Johanna Q. Miller
Rev. Frank A. Mathews Sr.
Dollar Tree, La Grange, N. C.
Francis Haddock
Dollar Tree, La Grange, Il.
Daniel L. Bach
South-West Auto Club
Susan B. Jordan, CPA
Jerri B. Evans
William Morris, Jr.
Dollar Tree, La Grange, Ky.
Southwest Regional Airport
Hans Bradshaw
Dr. Frank A. Mathews, Jr.
Numeric Filing
Directions: Place each group of numbers according to the numeric filing system in the
space provided.
Straight Numeric
Terminal Numeric
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1. 09248-97
2. 94009-98
3. 02736-91
4. 19985-98
5. 84755-98
6. 35594-99
7. 93747-92
8. 83790-99
9. 76630-96
10. 66655-96
11. 02836-91
12. 83610-99
13. 87330-91
14. 73660-97
15. 71740-92
3.02 Telephone Etiquette
Answering the phone
1. Speak clearly.
2. Use your normal tone of voice.
3. Use proper language.
4. Address the caller by his/her title (Good morning Mr. Doe.)
5. Listen to the caller and what they have to say. Repeat information if you are taking a
message to verify accuracy.
6. Be patient and helpful.
7. Always ask politely if you need to put someone on hold.
8. Always focus on the call. Try not to get distracted by others.
9. Do not eat or drink when talking on the phone.
Placing a call
1. Always identify yourself.
a. Name
b. Company name
c. Phone number
2. Always be aware of confidential information.
3. Always be aware of people around you. Be discreet.
4. Avoid leaving long messages. Keep it brief.
3.02 Scheduling Appointments
Correct scheduling of appointments is essential for good public relations. Computerized
systems specific to agency will be learned on the job.
Appointment Procedures
 Vary from office to office
 Computer Scheduling
 Computer automatically locates next available appointment
 Provides a record of appointments already scheduled
 Prints out copies of daily schedule
 Appointment book
 Time blocked in 15-minute intervals
 First…block out lunch, meetings, etc. with a large X
 Appointment time depends on purpose of appointment and would be determined by
the agency
 Some agencies use buffer period
When a patient calls…
1. Find out reason for call
2. Try to schedule convenient appointment for patient
3. Try to give choices
4. Be sure you have the required information before closing the call
5. Spell names correctly (ask if you don't know)
6. Write the patient's phone number in the appointment ledger
7. Repeat the date, time and important appointment details
8. Thank the caller and say good-bye
9. Double-check appointment book to assure correct time was blocked off
If the patient calls to cancel…
1. Ask if he/she would like to reschedule
2. Erase/delete appointment and reschedule
3. Do not ask why they are canceling
Scheduling issues…
1. In many agencies, patients who don't show up are billed
2. "No show" noted on patient's chart
3. If an emergency occurs and the health care provider is called away, sometimes all
appointments must be canceled
4. Sometimes, offices will make time for patients with emergencies to be seen
3.02 Maintain accounting records
What is the purpose of financial records? Used to record and analyze the financial
performance of a business.
What are financial statements? Reports that sum up the financial performance of a
business.
Asset records name the buildings and equipment owned by the business, original and
current value, and the amount owed if money was borrowed to purchase the assets.
Depreciation records identify the amount assets have decreased in value due to their
age and use.
Inventory records identify the type and number of products on hand for sale/use.
Records of accounts identify all purchases and sales made using credit. An accounts
payable record identifies the companies from which credit purchases were made and
the amount purchased, paid, and owed. An accounts receivable record identifies
customers that made purchases using credit and the status of each account.
Cash records list all cash received and spent by the business.
Payroll records contain information on all employees of the company, their
compensation, and benefits.
Tax records show all taxes collected, owed and paid. As a part of payroll, employers
must withhold a certain percentage of employees’ salaries and wages for federal
income tax. The company also makes payments for Social Security and Medicare and,
in some cases, for unemployment compensation.
3.02 Sample Budget
South Hills Healthcare, P. A.
123 American Boulevard,
Anytown, North Carolina 99999
Budget
Actual
Difference
$4,575,761.00
$3,303,137.00
$1,272,624.00
$2,355,182.00
$17,473.00
$64,768.00
$2,358,346.00
$27,272.00
$67,195.00
Pathology
Food Supplies
Domestic Services
Fuel, Light, Power,
and Water
$6,716.00
$57,866.00
$49,766.00
$67,245.00
$8,716.00
$53,828.00
$50,969.00
$89,235.00
Insurance
Motor Vehicle
Expenses
$68,849.00
$28,114.00
$68,849.00
$26,235.00
Repairs and
Maintenance
$38,334.00
$30,103.00
Maintenance
Contracts
$34,023.00
$34,023.00
$1,632.00
$211,746.00
$1,632.00
$167,339.00
$733.00
$1,733.00
$3,002,447.00
$2,985,475.00
Total Income
Expenses
Employee Salaries
Drug supplies
Medical and Surgical
Supplies
Patient Transport
Other Administrative
Expenses
Bad Debts
Total Expenses
Net Income