Medical Coding and Billing
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Health Information Management (HIM)

Health Information Management professionals (HIM) are specialists in data distribution, using computer software applications, word processing, database applications and electronic routing systems to send data and files to the appropriate individuals (in-house and external locations) to keep medical records up-to-date, coding accurate, billing current and a steady work flow going. All this is essential to efficiently managing large, or small health care facilities. HIM professionals work in the health information department usually in hospitals where they utilize database management systems to create data for medical records.

HIM Professionals

HIM professionals are not medical transcriptionists, or medical coders (although they go hand-in-hand!), rather they are experts in the field of patient health information, computer sciences (IT) technology and medical database administration and record management. HIM stands for Health Information and Medical Records Management.

Health information managers are responsible for the maintenance and security of all patient records. Recent regulations enacted by the Federal Government require that all healthcare providers maintain electronic patient records and that these records be secure. As a result, health information managers must keep up with current computer and software technology, as well as with legislative requirements. In addition, as patient data become more frequently used for quality management and in medical research, health information managers must ensure that databases are complete, accurate and available only to authorized personnel.

In group medical practices, managers work closely with physicians. Whereas an office manager might handle business affairs in small medical groups, leaving policy decisions to the physicians themselves, larger groups usually employ a full-time administrator to help formulate business strategies and coordinate day-to-day business. A small group of 10 to 15 physicians might employ 1 administrator to oversee personnel matters, billing and collection, budgeting, planning, equipment outlays, and patient flow. A large practice of 40 to 50 physicians might have a chief administrator and several assistants, each responsible for a different area of expertise.

What is A Medical Record?

A medical record, health record, or medical chart is a systematic documentation of a patient's medical history and care. It contains useful information stored on different types of media and characters, such as letters, numbers, or a combination thereof, for operational or legal purposes. Once hospitals and medical practices have converted to Electronic Health Records (EHR) the demand for HIM Professionals will instantly increase, probably double, or triple.

What is Database Management?

Databases consist of files, records, fields, columns and written characters. Managing, storing, retrieving and protecting databases falls well within the HIM department personnel scope of practice. To accomplish this task they usually utilize a Database Management System (DBMS). DBMS lets them create, store, modify, sort and retrieve the data.

HIM/Technical English Research Paper:

Re: Language and Culture of Medical CodersĀ«

I am a HIM student at Davenport University. I presently am taking a Technical English class and have to write a research paper about the language and culture of Medical Coders. I would appreciate anyone from the Health Information profession to answer some or all of these questions and return them to me. The questions are listed below. I will need your name as I have to have this information APA cited. Thank you. ~ Carol Ewing

1. What would you say is the most important aspect of working in the coding area of the Health Information Department?

Training, practice, experience, goal focus, business minded, punctuality, dedication, commitment, meeting deadlines, honesty, and integrity.

2. Do you think that the other areas of the department understand a coder's job really includes?

No. I believe other departments such as clinical nursing staff, health care technicians, allied health care professional; even doctors do not understand the scope, and full breadth of a medical coder's job.

3. What are the top five areas you would suggest so a non medical person could understand the coder's language and culture in a Health Information Department?

Plays a vital role in the patient health care setting, reviewing the patient’s charts, storing permanent medical files, documenting birth records/ newborn children birth certificates in hospitals.


4. What types of coding do you have to complete: inpatient, outpatient, laboratory, emergency, etc. or everything?

As a medical assistant, very simple coding-related tasks, such as circling codes on the patient encounter form, making sure the visit will be properly billed.

 5. How many coders are there within your health information department?

Working in a solo-medical practice, there were none. Coding and billing was done by the medical office supervisor, and administrative medical assisting staff (back office).


6. What is the most important advice you would say to a future medical coder?

Get proper training, communicate with your instructors, find a mentor, land a medical coding job in an area you like, work your way up, participate in workshops, networking, and continuing education classes.

 

7. What do you think the coder's job includes?

A medical coder's job includes attention to detail, matching diagnoses, and office visit (complexity), medical equipment and supplies with specific, matching alpha-numeric codes, which then go to the medical billing office.


8. How are some words that you would use to describe the language of a coder?

 I would best describe it at "industry specific lingo".

 

9. How is the language that coders used different from those in other areas of the HIM department?

I believe the language contains medical terminology, diagnostic terms, and words related to health care insurance processing, and claims submission, while the HIM department uses terminology related to computer sciences, database management, software input- and output devices, and patient records management. However, in order to keep the workflow going, both speak the lingo of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and also must understand proper use of medical terminology, diagnostic terms, and various terms related to the health insurance industry, and medical office admin areas.

 

10. What are some words that you would use to describe the culture of a coder?

While many quite successful medical coders have been trained right on the job, health informatics or medical informatics requires education in IT information science, computer science, and health care, medical records administration.


11. How is the culture of the coders difference from those in other areas of the HIM department?

Both, medical coders and health information department personnel are a vital part of the health care industry as a whole. I believe that what sets them apart is that medical coders mostly deal with (examining) patient charts and insurance plans to make sure that the doctor gets paid for services, while the HI department deals with creating and managing very large patient record databases via computer input devices, and software programs, and storage of medical records in digital format, and print. Medical coders often have to contact the HI department to obtain copies of medical records. I feel medical coders are business managers, and consultants by nature, while health information department members are more of technical and computer gurus by nature.


12. List some examples:

Hot coffee, desks of paperwork, pencil holders, telephone, vs. computer screens, CPUs, mouse pads, and FAX machines.


13. Name some of the different type of areas within the HIM department?

Medical records processing and storage, medical record review, medical record distribution, forms management and research, release of information.


14. What is the job description for a medical coder?

The job of a medical coder includes interpreting patient's medical charts and assigning the appropriate diagnostic and procedural codes for reimbursement. They use the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) which is accepted and used world-wide.


15. What type of education requirement do the coders in your place of employment have?

2 years of experience and certification.

Reply #1 on Medial Billing Community:  Yesterday at 05:44:16 PM Ā»

 
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