Guided Notes

The Health Information Management

1. What functions does the HIM department serve? The keeper of medical records
 Support health services research.
 Maintain records for utilization management, risk management, and quality
management or performance improvement programs.
 Ensure patient privacy and security issues, along with compliance with legal
requirements
 Perform other extraneous patient services.
 Review records for completeness
 Use records to code visits for billing purposes

 Manages the patient medical record in any format. To ensure that patient record is
completed accurately and timely so that the information available to the care
providers and patient while still ensuring privacy and confidentiality. That is
needed to deliver health care services and to make appropriate health care related
decisions. Ex: histories and physicals
 Supports the current and continuing care of patients; the institution’s
administrative processes; patient billing and accounting processes; medical
education programs; health services research; utilization management, risk
management, and quality management or performance improvement programs;
privacy and security issues related to HIPAA; legal requirements: and extraneous
patient services.

2. How long must records be maintained?

Minimum of 5 years from date of last patient visit for adults and up to the 18th birthday
or 5 years from date of last visit (whichever is greatest)

3. For each of the codes sets, write out what the acronym stands for, who maintains the
code set, and how is each code set used: classification system that is used for diagnosis
coding in all health care settings in the United States
ICD-10 (International Classification of Diseases)
 Maintained by WHO (world health organization) – began using in May 1990 –
ICD11 was released June 2018 and will begin use in January 2022
 Used to track mortality rates internationally (death certificates)
 Exposure to ionizing radiation: W88
ICD-10-CM (International Classification of Diseases, 9th edition, Clinical Modification):
 Used code and classify morbidity data from inpatient and outpatient records and
physician offices
 Acute upper respiratory infections-influenza virus with other respiratory
manifestations: J09.X2, J10.1, J11.1
  HIM coders will scour through records and pick out key words and phrases to
determine the most accurate way to code the office visit or inpatient stay. These
codes determine how much the hospital or doctor will be reimbursed for the care
received by the patient.
 The clinical modification code set is maintained by the CDC.
ICD-10-PCS (international classification of diseases – procedure coding system)
 Maintained by Centers for Medicare and Medicaid Services (CMS)
 Used to report procedures performed in a hospital setting
o Right forearm (plain radiography): BP0JZZZ
o Upper GI fluoroscopy exam: BD15YZZ
CPT: Current Procedural Terminology (HCPCS Level I)
 Code set used to identify medical services and procedures performed by physicians
and other health care professionals. This code set is maintained by the American
Medical Association of AMA.
 Chest x-ray 2 views: 71046
o 71046-TC – technical charge for exam from rad tech
o 71046-26- professional charge only for radiologist interpretation
 Pay two different codes
HCPCS (Level II) healthcare common procedures coding system (hics-pics)
 Alpha-numeric coding systems used to identify products, supplies and services not
included in the CPT codes (ambulance services, durable medical equipment,
prosthetics, orthotics, supplies, etc.)
 Maintained by CMS
 Transport portable x-ray machine to home or nursing home: R0070