HIM2252 PPE Packet 11_02_23 (1)
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Sinclair Community College *
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Feb 20, 2024
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Sinclair Community College
Health Information Management
HIM 2252
PROFESSIONAL PRACTICE EXPERIENCE (PPE)
Revised November 2, 2023
The following assignments are required
for the Professional Presentation PPE portion of HIM 2252.
Orientation to HIM Department
Eleven additional assignments selected by the student
Activity Logs Assignment Due Dates Professional Presentation PPE assignments must be submitted in an assignment drop box in the course according to the schedule below:
At least two assignments are due every two weeks.
All graded assignments are due by the end of the 15
th
week of the semester.
Two Tracks!
Remember, this Professional Presentation PPE portion of the course has two tracks: 1) Accumulated PPE hours and 2) PPE assignments.
1) Accumulated PPE Hours - Activity Log Journal
Activity Logs serve as the student’s documented journal of his/her PPE activities during the Professional Presentation PPE portion of HIM 2252. Your activity is recorded in the discussion forum
titled, Activity Log Journal
. The documentation required for every presentation that you participate in and/or watch is described in the instructions of the discussion forum. Although there is no grade
associated with your posts, this is the mechanism for tracking your 60 required Professional Presentation PPE hours
. Your post for each presentation is due within three days of your participation/review. This tight deadline allows your instructor to assure you are continuing to engage in the presentations available in your Professional Presentation PPE portion. Your instructor reads each post and checks the previous post to verify a running accumulation tally of the completed Professional Presentation PPE hours. Further information about Activity Logs is provided within the course. 2) PPE Assignments – Graded Reports
For this portion, you are required to participate/review at least 12 different presentations
. For each presentation, a written report is required. Some presentations have an associated outline for you to follow in your report. For each assignment (#1 – 23 in the following list), you are provided an outline for you to follow as you
watch the presentation and write your report. It is highly recommended that prior to the presentation, you should review the outline in preparation for taking notes during the presentation, which will, in turn, assist you in writing your report. Some presentations (#24) are not included in the list in this packet and therefore you are required to complete/write a minimum 2-page report.
For each report, a coversheet is required
. This coversheet is provided for you below and should be
the first page of each report. This coversheet does NOT count as a page in the required minimum 2-
page report.
1
Evaluation Criteria Coversheet
Student Name:
Facility Name: Assignment #:
Assignment Topic: CRITERIA
ACTUAL
POINTS
MAXIMUM
POINTS
1.
Student’s submission includes all details (including a
minimum of 2 pages not including this coversheet) as specified for the assignment. (Narrative reports are to be double spaced.)
9
2.
Grammar, proper punctuation, use of possessives, spelling and sentence structure are correct.
6
3.
Answers to questions/statements typed in a neat fashion after specific questions or on provided line; 1-inch margin; 12-point font (Arial preferred); error free; word processed; saved as a .docx document.
4
4.
Evaluation Criteria Coversheet attached as first page
1
TOTAL
20
Comments from Sinclair PPE Course Instructor:
2
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HIM 2252 – Professional Presentation PPE
List of Possible Presentations
The list below represents the typical presentations offered each year. However, the actual presentations offered this year depend upon the availability of HIM presenters.
Students Should Use This Form to Record Their Scores
Assignment
Presentation Topic
Maximum
Points
Your
Points
Assignment 1*
Orientation to the HIM Department Questionnaire*
20
Assignment 2
Prepping, Scanning & Indexing Process
20
Assignment 3
Analysis
20
Assignment 4
The Role of the HIM Manager
20
Assignment 5
Physician Incomplete/Delinquent Record Process
20
Assignment 6
Medicolegal Process Evaluation of Competency
20
Assignment 7
Coding Coordination Questionnaire
20
Assignment 8
Ambulatory Coding Evaluation
20
Assignment 9
Patient Registration 20
Assignment 10
Patient Accounts
20
Assignment 11
Statistics Questionnaire
20
Assignment 12
Transcription Processing Report
20
Assignment 13
Ergonomics Assessment of an HIM Area
20
Assignment 14
Electronic Health Record Questionnaire
20
Assignment 15
Job Procedure
20
Assignment 16
Privacy Officer/HIPAA Questionnaire
20
Assignment 17
Clinical Data Abstracting in the Tumor/Cancer Registry
20
Assignment 18
Charge Description Master Questionnaire
20
Assignment 19
Job Description
20
Assignment 20
RAC Coordinator/Manager Questionnaire
20
Assignment 21
Revenue Cycle Assignment
20
Assignment 22
Coding Training Questionnaire
20
Assignment 23
Patient Portal 20
Assignment 24**
Other Presentation Topics**
20
*Mandatory for all students to complete/submit.
** The list of Assignments #1 through #23 above is not all-inclusive. There are other HIM-related topics that are presented throughout the semester.
3
Assignment #1 (mandatory for all students)
Orientation to the HIM Department Questionnaire
Worth 20 points
Instructions for PPE Site Supervisor: Students should receive general information about the healthcare facility and the HIM Department in order to complete the Orientation to the HIM Department Questionnaire.
Be sure to inform students of any typical HIM department policies and/or procedures that they should be aware of. Specific areas to cover may include dress code, parking availability, behavior expectations, tardiness and absenteeism, confidentiality of the records, etc.
Instructions for Students:
The purpose of this questionnaire is to aid students in understanding the functions and services provided by the healthcare facility and specifically the HIM department. A copy of the questionnaire follows. Students should copy the questionnaire and paste it into a new word-processing document to complete it. Handwritten assignments are not acceptable.
Expectations
:
Typed answers for each question/statement, 1-inch margin, 12-point font.
Document saved as a .docx file.
Evaluation Criteria Sheet (provided above) as the first page of the document.
Assignment submitted in the appropriate drop box.
4
Student Name: Facility Name:
Orientation to the HIM Department Questionnaire
1.
Name and address of facility: -
Kettering Health: Located in main campus Kettering, OH
-
Administrative buildings in Miami’s Burg
-
Building by the Dayton Mall with a K on it, where a lot of network service departments are located. 2.
Type of services provided:
-
Ketter Health services provided: Babies, orthopedics, behavioral health, cardiology, oncology.
-
Provide most services
-
Funnel younger kids over to children; do not provide a lot of pediatric stuff 3.
Type of ownership:
-
No real straight answer -
Non-profit, have board of directors, no single person owns
*Additional Info*
-
Associated with religious: Yes, founded by Charles Kettering, an individual that hold most patterns for anyone country. maybe the world. After starting the hospitals either Charles or his family member received such good care at a Seventh Day Adventist hospital. This experience prompted him to bring the Seven Day Adventist church into his hospitals organizations and run it. He thought they gave great coordinated care, so he implemented them into his sites. Kettering is still ran by the Seventh Day Adventist organization. 4.
Number of physicians on staff: -
Over 1200 physicians on staff cross the whole network -
Contract out ED providers: Not Kettering employees, but contracted service with a group of
physicans. 5.
Number of adult beds: -
Current registration for January 2024, 1388 beds across network 6.
Number of newborn beds: -
17, 48, 8, 28, 33, 26, 6 = 166 -
166 Newborn beds across the network *Additional Info*
-
Across the network, do not deliver babies at all facilities. -
Deliver babies at: Hamilton (Located more in Cincinnati market Hamilton, Ohio), Washington Township (Formerly known as Southview), Main Campus (Kettering Location),
at some point in Beavercreek.
7.
Number of pediatric beds: -
Do not have designated pediatric beds because they try to sent those patients over to Children’s. -
They do orthopedics on some older, more teenage kids if they come in for orthopedic. 8.
Is there a physician residency program at this facility?
-
Across network, teaching facility they have residents at all their campuses except Hamilton
-
Residents come from Wright State Medical School
-
Ohio University has aa DO program, Doctors of Osteopathic Medicine 5
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9.
If yes, provide the type of residency program(s) and the university it is affiliated with.
-
Kettering Health at the total network -
Numbers are based on network numbers, not any specific site. -
Recently went through rebranding, previously has been called Kettering Health Network, now just Kettering Health. -
They are trying to make locations tied to location, name tied to the catering house -
Have now Kettering Health Miami Spring instead of Kettering Health Sycamore. Same with
Washington Township. Kettering Health Washington Township formulary known as Kettering Health Self View, trying to tie location to the name of network. -
See info for Seventh Day Adventist affiliation and about Chales of Kettering in about *Addition Info* in pervious questions answers. 10. Is this facility part of a healthcare network? 11. If yes, specify the name of the network and a few other facilities within the network. 12. List other interesting items about the facility: 13. Name and credentials of the Health Information Management Department Director: -
Angie Roden
-
Official Title: Network director of Him’s operation -
Credentials: MHRA (Master of Health Care Administration), RHIA through AHIMA. 14. Which division is the HIM Department a part of in the facility? (i.e. medical services, financial, etc.) -
Medical Records, floats around over the years. They are a part of quality, different departments. Currently under revenue cycle and fall under the midriff cycle piece. -
There is front end rev cycle; scheduling, pre certifications, registration
-
Middle piece; scanning, working with physicians to ensure they get their OB notes completed so they can be coded. -
Once coded, falls into end of cycle; billing, patient accounts, denials, and all other kinds of functions. -
All reve cycle is HIM work *Additional Info*
-
Anyone that has an HIM degree is a great fit for either scheduling, press, registration, all midriff cycle stuff ass well, coding, chart completion, also in all in end cycle functions, billing, denials, working with the insurance, all HIM work, very interesting. 15. How many employees are in the HIM Department? -
Our division is utilization management, nurses come in make sure patients are in the right status. -
Our clinical documentation Improvement team falls under mid-rev cycle. They are working with Physicians to improve documentation. -
Ensure naming things correctly, full story of what is going on with the patient -
HIM operations within the recycle, about 180 at Kettering Hill, -
Includes the teams overseen as well as inpatient coding outpatient coding and professional
coding. *Additional Info*
-
Pro fee coding: In in some courses we will take yes. Sinclair focus on Hospital coding in the very beginning. The very first course is all about introduced as Physician Office coding Department.
-
They value Sinclair grads, offers onsite training while doing their professional coding. Kettering’s coding training program is very robust so enter being unsure what pro fee. Will 6
receive a great understanding of how it all ties together to the inpatient piece or the ambulatory piece.
16. How many employees in the department are credentialed? -
Every changing number because constantly hiring new people -
Kettering allows uncredentialled employees a years to get their credentials -
All coders must be credentialed -
Higher team members and shirt completion teams that have R certifications
Number of RHIA:
Number of RHIT:
Number of CCS:
Number of CCS-P: 17. If there are other credentialed employees, list their credential and the organization that awards
the credential:
18. How many employees work remotely?
19. Specify the job title, job function and the remote location where they work.
20. List the department hours of operation:
21. If the department is open nights and/or weekends how many employees work and what are their major functions?
22. How is the department covered after business hours if no one is scheduled to work?
23. What role does the HIM department play in assuring post-discharge caregivers (for IP discharges) receive a copy of the patient’s discharge instructions?
24. Which of the following storage systems does this department utilize and what years are in that format? Check all that apply.
Filing shelves for paper records from to
Filing cabinets for paper records from to
Microfiche from to
Roll microfilm from to
Electronic/paperless/hybrid records from to
Off-site storage of paper records from
to 25. Name of off-site storage company/facility, if utilized.
26. Describe quality control systems in place to ensure filing accuracy of stored medical records and the frequency of such monitoring actions.
27. Has the facility destroyed records within the last 5 years? 28. If so, how were they destroyed? 29. If a company was used in the destruction process, list the name and how they handled the destruction.
30. Approximately how often are medical records older than 5 years accessed? 31. What are the most common reasons to access medical records older than 5 years?
7
32. If any type of microfilm storage is used, where are readers and/or reader-printers located?
33. If the facility utilizes an EHR/paperless system, what is the name of the EHR? 34. Briefly describe any HIM department policies/procedures that we should be aware of?
8
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Assignment #2
Prepping, Scanning & Indexing Process
Instructions: As the HIM professional is presenting information about the scanning process, students should take notes and ask appropriate questions. This assignment is worth 20 points.
Expectations:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Your report should cover, but is not limited to the following topics:
Who manages the scanning process? Credentials? Experience?
Describe the scanning staff. FTEs? Credentials? Work schedule?
The steps involved in the prepping, scanning, and indexing process overall. Provide any statistics discussed during the presentation. What types of documents are scanned?
Does the facility utilize bar codes? If so, describe and explain.
How are quality reviews conducted? Describe typical errors noted. Include any details of the quality process if quality thresholds are triggered.
What are the qualifications for a new hire? How long is the training for a new hire?
9
Assignment #3
Analysis
Instructions: As the HIM professional is presenting information about the health record analysis process, students should take notes and ask appropriate questions. This assignment is worth 20 points.
Expectations:
The presenter proves the assessment for additional analysis.
Your submission reflects a competent analysis of health records as demonstrated in the presentation.
Your report must be typed with 11-12-point font (Arial preferred).
The document saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Instructions for Students
After the presentation, an assessment is provided which includes up to 10 additional health records that require quantitative analysis. Each student should review and perform the quantitative analysis procedure for medical records, focusing on the major component deficiencies using the facility’s procedure. Answers should be indicated on the assessment document. Students must include the Evaluation Criteria Coversheet as the first page. 10
Assignment #4
Role of the HIM Manager Instructions: The HIM manager, whether it be the departmental supervisor or the department director, wears many different hats throughout the day. As the HIM manager is presenting information about his/her many job responsibilities, students should take notes and ask appropriate questions. This assignment is worth 20 points
.
Expectations:
Your report reflects the data and information presented. Use the bolded subheadings from the 6 categories below.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Your report should cover, but is not limited to the following:
1.
A direct supervisor of employee activities
Describe how many and what type of employees the supervisor manages.
Explain the supervisor’s role in regulatory quality monitoring.
2.
An overall department manager
Recount the major components of the managers' job description.
Describe a typical day.
Describe the process for hiring and training a new employee.
Describe the process of monitoring and ordering supplies needed for HIM work processes.
Describe how the time/attendance monitoring is accomplished.
3.
A committee member/resource person
List the committees that the site supervisor serves on and describe their role on the committee.
Are department meetings held? If so, how often? Onsite or remote?
4.
A consultant to the medical staff, administration, and other direct care providers regarding documentation
Summarize how the manager serves as a “content expert” to others in the facility.
Is the manager on any community Advisory Committees?
5.
An educator
Describe how the supervisor educates his/her employees in terms of in-services, department meetings, overall continuing education, etc.
How is the manager involved with higher education programs (such as Sinclair)
6. Systems Manager
Describe the manager’s responsibilities with the EHR and any other system utilized by HIM.
11
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Assignment #5
Physician Incomplete/Delinquent Record Process
Instructions: Students should become familiar with the HIM department’s system of tracking incomplete and delinquent records, whether it is a manual or computerized system. Students should learn about the "chart count" and physician notification process. In addition, students should become aware of and understand the facility’s policy concerning reinstatement of physician privileges after admitting privilege suspension. As the HIM professional is presenting information about the physician's incomplete/delinquent record process, students should take notes and ask appropriate questions. This assignment is worth 20 points.
Expectations
:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
The following list of ideas/thoughts/concepts should be addressed, if applicable, in the assigned paper based upon students' observations and investigations at the PPE site. This is by no means a complete or comprehensive list of discussion points. Additional information may be included to fully describe this function.
1.
How are incomplete and delinquent records processed in this facility?
2.
How are attending physicians’ records/deficiencies handled? How are resident physicians’ records/deficiencies handled? Is there a difference? Why?
3.
Describe the physician's incomplete record area. Is there one? If so, how many physicians come to the incomplete record area? What is the atmosphere between the physicians and the HIM staff in this area?
4.
How is this area staffed? Onsite? Remote? How many hours per week? Days? Nights? Weekends?
5.
Is any special training required for staff to work in this area?
6.
Are any special records handled differently? If so, how? Explain in detail.
7.
How long do the physicians have to complete the records after discharge?
8.
At what point in time are the records considered to be delinquent?
9.
How do physicians know which deficiencies to complete? How are the deficiencies marked/queued? (i.e. What electronic indicators are utilized? In which order do the deficiencies appear? Are “older” deficiencies prioritized over “less-aged deficiencies?)
10. How are the physicians notified of deficient records to be completed? (If residents are at this facility, is there a difference in the way attending physicians are notified vs. residents?) 11. What kinds of excuses are usually given as to why the physicians cannot complete their records?
12. Are physicians “punished” for incomplete and delinquent records? How?
13. Do other departments know when the physicians have not completed their records? Which departments? How are they notified?
14. How is computer downtime handled for the incomplete/delinquent record process? 15. Are any quality assessment activities performed to ensure data accuracy?
12
16. After reviewing this process, do you have any suggestions for improvement?
17. Would you enjoy working in this area? Why or why not?
13
Assignment #6
Medicolegal Process Evaluation of Competency Instructions: Students should become familiar with the HIM department’s medicolegal activities. As the HIM professional is presenting information about the physician's incomplete/delinquent record process, students should take notes and ask appropriate questions. This assignment is worth 20 points.
Expectations
:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
The presenter will review with you some typical requests. Your report should cover, but is not limited to the following topics:
1.
Who manages the Release of Information
(ROI) area? Credentials? Experience
2.
Describe the ROI
staff. FTEs? Credentials? Work schedule?
3.
Describe the overall steps in the ROI process when a request is received. Include various requests such as mail, walk-in, and phone calls. Include logging requests and continue through to distributing the requested information.
4.
Name typical types of requestors. (patients, family members of patients, attorneys, other healthcare providers…) 5.
Review requests and authorizations for validity and take the appropriate action for requests that are determined to be invalid.
6.
Describe the steps for handling a request that is denied.
7.
Communicate the data that is recorded in the log system.
8.
Define the circumstances where payment is requested. Describe the billing fees in detail.
9.
Determine the various acceptable charges and for which mediums.
10. Describe the process and steps taken when a subpoena vs a court order is received. If the HIM professional has questions, what chain of command is followed?
11. Is a copy service used? If so, what are the advantages and disadvantages? 12. Review the policies and procedures concerning release of and fax transmittal of health information
and confidentiality concerning drug and alcohol; psychiatric and other sensitive protected health information.
13. Are the employees in the ROI area required to be notaries?
14. Would you enjoy working in this area? Why or why not?
14
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Assignment #7
Coding Coordination Questionnaire
Instructions: Medical coding for a hospital is typically divided into four groups. Therefore, the focus of this assignment will reflect four parts and may incorporate several presentations for completion. Students should have their coding books during the presentation to participate in the coding activities. This assignment has four (4) parts and in total is
worth 20 points.
If coding is performed at a corporate office for an entire network of hospitals, please explain to students how this works for the employees. Are the coders expected to work with health care records
from just one hospital or all of the hospitals in the network? Do the coders work at home, in the corporate office, or a combination of both?
A copy of the questionnaire follows. Students may print the Coding Coordination Questionnaire to take notes as they participate in the coding process. However, once the data is gathered, students should copy the questionnaire and paste it into a new word-processing document to complete it. Expectations
:
Your report reflects the data and information presented.
Each presenter’s name must be included in the report.
Use the questionnaire for your submission. Your answers for each question may be single-spaced but there must be a space between each question. A font of 11 or 12 points is required. (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Note: There are 4 parts to this assignment as follows. All parts must be completed to earn the 20 points for this assignment.
15
ASSIGNMENT #7
Coding Coordination Questionnaire
Part 1 – Diagnostic Coding
Name of the medical facility and the manager(s) in charge of diagnostic coding:
1.
Describe the type of records coded.
2.
Which type of coding method(s) are primarily used?
Coders use their coding books
Encoders
If so, name of encoder:
A combination of both is used
Computer Assisted Coding If so, name of system used:
3.
List the medical documents/information routinely reviewed during the coding process.
4.
Do diagnostic coders code for allergies? Social determinants? External causes?
5.
At what point are these records coded? (Before service?, after service?)
6.
Is a principal procedure generally identified/coded? If not, where does the test/procedure code come from?
7.
What are the minimum qualifications for a diagnostic coder position?
8.
Is there a minimum work standard for the number of diagnostic accounts coded per day? If so, explain how this productivity is monitored. 9.
Explain and provide details describing how coding quality audits are conducted and how these results are shared with coders. 10.
How many coders are presently employed in diagnostic coding? How many are full-time and how
many are part-time?
11.
Do coders work remotely (from home)? Do they work at the corporate office? What is the determining factor (productivity? quality? time on the job?) that permits a coder to work remotely?
12.
If coders work remotely, is there a productivity or error threshold that will bring them back into the HIM Department or corporate office for additional training or to code under closer supervision? 13.
Do the coders have fixed schedules, or can their working hours be flexible as long as the required
number of hours is worked? Is their work week based on the number of records coded? Explain.
14.
Explain the role of the coding supervisor/coordinator in monitoring coding and coding production.
15.
Explain the orientation and training for a diagnostic coder.
16.
Explain how the diagnostic coding process is a team effort at this facility.
17.
Are there coding meetings for diagnostic coders? How often do these meetings occur? Are the meetings conducted “virtually” or are coders required to meet onsite?
16
18.
Is this facility investigating/utilizing computer-assisted coding for diagnostic coding? If so, please provide details.
Part 2 – Emergency Department (ED) Coding
Name of the medical facility and the manager(s) in charge of Emergency Department coding:
1.
Describe the type of records coded. 2.
Which type of coding method(s) are primarily used?
Coders use their coding books
Encoders If so, name of encoder:
A combination of both is used
Computer Assisted Coding If so, name of system used:
3.
List the medical documents/information routinely reviewed during the coding process.
4.
Do ED coders code for allergies? Social determinants? External causes?
5.
At what point are these records coded? (Before or after qualitative/quantitative analysis?)
6.
How are the principal diagnosis and/or principal procedure generally identified?
7.
Do the ED coders perform charging? If so, explain charging.
8.
What are the minimum qualifications for an ED coder position?
9.
Is there a minimum work standard for the number of emergency department records coded per day? If so, explain how this productivity is monitored. 10.
Explain and provide details describing how coding quality audits for ED coders are conducted and how these results are shared with coders.
11.
How many coders are presently employed in ED coding? How many are full-time and how many are part-time?
12.
Do ED coders work remotely (from home)? Do they work at the corporate office? What is the determining factor (productivity? quality? time on the job?) that permits a coder to work remotely?
13.
If ED coders work remotely, is there a productivity or error threshold that will bring them back into the HIM Department or corporate office for additional training or to code under closer supervision?
14.
Do ED coders have fixed schedules, or can their working hours be flexible as long as the required number of hours is worked? Is their work week based on the number of records coded?
Explain.
15.
Explain the role of the coding supervisor/coordinator in monitoring coding and coding production for ED coding.
16.
Explain the orientation and training for an ED coder.
17.
Explain how the emergency department coding process is a team effort at this facility.
17
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18.
Are there coding meetings for ED coders? How often do these meetings occur? Are the meetings conducted “virtually” or are coders required to meet onsite?
19.
Is this facility investigating/utilizing computer-assisted coding for ED coding? If so, please provide details.
Part 3 – Ambulatory Surgery/Outpatient Surgery Coding
Name of the medical facility and the manager(s) in charge of ambulatory surgery coding:
1.
Describe the type of records coded.
2.
Which type of coding method(s) are primarily used?
Coders use their coding books
Encoders
If so, name of encoder:
A combination of both is used
Computer Assisted Coding If so, name of system used:
3.
List the medical documents/information routinely reviewed during the ambulatory surgery coding process. 4.
Do ambulatory surgery coders code for allergies? Social determinants? External causes?
5.
At what point are these records coded? (Before or after qualitative/quantitative analysis?)
6.
How are the principal diagnosis and/or principal procedure generally identified?
7.
Do the ambulatory surgery coders perform charging? 8.
What are the minimum qualifications for an ambulatory surgery coder position?
9.
Is there a minimum work standard for the number of ambulatory surgery records coded per day? If so, explain how this productivity is monitored. 10.
Explain and provide details describing how coding quality audits are conducted for ambulatory surgery coding and how these results are shared with coders. 11.
How many coders are presently employed in ambulatory surgery coding? How many are full-
time and how many are part-time?
12.
Do ambulatory surgery coders work remotely (from home)? Do they work at the corporate office? What is the determining factor (productivity? quality? time on the job?) that permits a coder to work remotely? 13.
If ambulatory surgery coders work remotely, is there a productivity or error threshold that will bring them back into the HIM Department or corporate office for additional training or to code under closer supervision? 14. Do ambulatory surgery coders have fixed schedules, or can their working hours be flexible as long as the required number of hours is worked? Is their work week based on the number of records coded? Explain. 18
15. Explain the role of the coding supervisor/coordinator in monitoring coding and coding production for ambulatory surgery coding.
16. Explain the orientation and training for an ambulatory surgery coder.
17. Explain how the ambulatory surgery coding process is a team effort at this facility.
18. Are there coding meetings for ambulatory surgery coders? How often do these meetings occur? Are the meetings conducted “virtually” or are coders required to meet onsite?
19. Is this facility investigating/utilizing computer-assisted coding for ambulatory surgery? If so, please provide details.
Part 4 – Inpatient (IP) Coding
Name of the medical facility and the manager(s) in charge of inpatient coding:
1.
Describe the type of records coded.
2.
Which type of coding method(s) are primarily used?
Coders use their coding books
Encoders
If so, name of encoder:
A combination of both is used
Computer Assisted Coding If so, name of system used:
3.
List the medical documents/information routinely reviewed during the IP coding process.
4.
Do IP coders code for allergies? Social determinants? External causes?
5.
At what point are inpatient records coded? (Before or after qualitative/quantitative analysis?)
6.
How is the principal diagnosis and/or principal procedure generally identified in IP coding?
7.
Do the IP coders perform charging? 8.
What are the minimum qualifications for an IP coder position?
9.
Is there a minimum work standard for the number of IP records coded per day? If so, explain how this productivity is monitored. 10.
Explain and provide details describing how coding quality audits are conducted for IP coding and how these results are shared with coders.
11.
How many coders are presently employed in IP coding? How many are full-time and how many are part-time?
12.
Do IP coders work remotely (from home)? Do they work at the corporate office? What is the determining factor (productivity? quality? time on the job?) that permits a coder to work remotely?
13.
If IP coders work remotely, is there a productivity or error threshold that will bring them back into the HIM Department or corporate office for additional training or to code under closer supervision?
19
14.
Do IP coders have fixed schedules, or can their working hours be flexible as long as the required number of hours is worked? Is their work week based on the number of records coded? Explain.
15.
Explain the role of the coding supervisor/coordinator in monitoring coding and coding production for IP coding.
16.
Explain the orientation and training for an IP coder.
17.
Explain how the IP coding process is a team effort at this facility.
18.
Are there coding meetings for IP coders? How often do these meetings occur? Are the meetings conducted “virtually” or are coders required to meet onsite?
19.
Is this facility investigating/utilizing computer-assisted coding for IP surgery? If so, please provide details.
20
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Assignment #8
Ambulatory or Inpatient Coding Instructions: Students should be involved in coding ambulatory or inpatient medical records. There is
no set number of medical records to be coded. The value and object of this assignment is for students
to experience coding a “real world” EHR record alongside an HIM coder. As the HIM professional is presenting information about the coding process, students should take notes and ask appropriate questions. This assignment is worth 20 points
.
Students should have their coding books available to participate in the coding activities.
Instructions for Students:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Your report should cover, but is not limited to the following:
Include the type of medical record coded. (ambulatory surgery vs IP).
Describe in detail the steps and thought process for coding the diagnoses and procedure.
Describe in detail how the EHR came into play with the coding process.
Describe in detail the steps in using computer-assisted coding (if applicable).
Describe the hints and tips that were shared by the coder.
Explain any “aha” moments that occurred for the coder or for you during the demonstration.
Depict any coding instruction or any part of the presentation that you felt “I got this!”
Reflect on this experience overall and how it improved your confidence and eagerness for coding (or not).
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Assignment #9
Patient Registration
Instructions: Students should explore the activities and functions associated with Patient Registration. As the presenter reviews information about the Patient Registration area, students should take notes and ask appropriate questions. This assignment is worth 20 points
.
Expectations
:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the
document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Your report should cover, but is not limited to the following:
1.
Include the Patient Registration manager’s name.
2.
Describe a typical day on the job for a Patient Registration professional.
3.
Explain how a patient's medical record number and account number are assigned on admission.
4.
Explain how the pre-registration process integrates with the registration process.
Approximately what percent of patients are pre-registered?
Who performs this function?
5.
Describe the information that is provided to the patient on admission, e.g. information forms, patient bill of rights, advance directives, patient privacy forms, etc.
6.
Include any information about the consent forms that are signed during the admissions process. Is an electronic signature utilized?
7.
Describe the procedure involved in the admission of a patient and how patients provide proof of identity.
8.
Depict if/how insurance information is gathered.
9.
If applicable, describe the process Patient Registration individuals follow to scan any documents or information into the EHR. 10. Explanation of the ABN process and why it is important.
11. Describe the role of the Patient Registration Department in the revenue cycle.
12. Explain the relationship of the Patient Registration Department with the HIM Department and the Patient Accounts (Billing) Office.
13. Explain any “aha” moments that occurred for you during this presentation.
22
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Assignment #10
Patient Accounts
Instructions: Students should explore the activities and functions associated with Patient Accounts with an emphasis on activities involving Medicare, Medicaid, BC/BS, Worker’s Compensation, and billing. As the presenter reviews information about the Patient Accounts/Billing area, students should take notes and ask appropriate questions. This assignment is worth 20 points
. Expectations:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Your report should cover, but is not limited to the following:
1.
Include the Patient Accounts manager’s name.
2.
Describe a typical day on the job for a Patient Accounts professional.
3.
Describe the completion of the Universal Bill.
4.
Describe a UB-04.
5.
Explain the process of receiving denials, resubmitting claims and the reasons for denials.
6.
Explain the process to appeal insurance claim denials.
7.
Explain the difference between a rejected claim vs. a claim that is denied.
8.
Describe the processes involved when billing third-party payers, processing accounts receivables, monitoring payments, and verifying insurance coverage.
9.
Explain the coordination of benefits.
10. Explain a payor portal.
11. Describe the role of the Patient Accounts Department in the revenue cycle.
12. Describe the relationship between Patient Accounts and the HIM department.
13. Explain any “aha” moments that occurred for you during this presentation.
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Assignment #11
Statistics Questionnaire
Instructions
: Healthcare data must be as complete and accurate as possible since it is the basis of the statistical information that is created upon which many facility and patient care decisions are formed. The focus of this presentation is specifically HIM department statistics. Discussion will include the types of data captured to create information for decision-making plus data collection and reporting methods. Students will complete the Statistics Questionnaire.
A copy of the Statistics Questionnaire follows. Students may print the questionnaire to take notes as they participate in the statistics process. However, once the data is gathered, students should copy the questionnaire and paste it into a new word-processing document to complete it. This assignment is worth 20 points
.
Expectations:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single-
spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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Statistics Questionnaire – Assignment #11
Student Name:
Facility Name:
Presenter’s Name:
Facility Statistics
1.
Provide a brief description of how the HIM department is involved with gathering or receiving statistics (e.g., what data is gathered, who is responsible, how is this facility information shared
with HIM staff, etc.) 2.
Who is responsible for generating, contributing to, or providing a quality review of facility statistical data in the HIM Department? 3.
Explain the procedure for the completion of birth and death certificates. Include information concerning who is responsible in the facility for the completion. 4.
Provide the following information concerning this facility’s statistics for adults and children for the last full calendar year.
Percentage of Occupancy: Average Length of Stay: Average Daily Census: Number of Admissions: Number of Discharges: Number of Births: HIM Department Statistics
5.
Discuss the various statistics and statistical reports that are generated in or used by the HIM Department. Consider the following areas.
List the number of records (inpatient and outpatient) that must be scanned per day or per employee. Are there quality measures in the scanning area?
List the average number of release-of-information requests received per week or month.
What is the expected and actual average turnaround time for ROI requests?
List the diagnostic coding productivity and quality requirements.
List the ambulatory surgery coding productivity and quality requirements.
List the inpatient coding productivity and quality requirements.
6.
What other statistics are collected and/or monitored in the HIM department? (consider DNFB statistics, days in AR statistics, percentage of delinquent records for accreditation, turnaround time for ROI, etc.)
7.
Why is it important to implement productivity and quality requirements for various job functions?
8.
Describe how the statistics class you completed at Sinclair Community College helped you understand the statistical activities at this facility. 25
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Assignment #12
Transcription Processing Report
Instructions: Students should explore the Transcription Processing area of the HIM Department. If the facility outsources its transcription functions, students should concentrate on the areas below indicated with an asterisk (**). This assignment is worth 20 points
.
Expectations:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
Your report should cover, but is not limited to the following topics:
1.
Who manages the Transcription Processing area?
2.
Describe the staffing level and hours of the Transcription Processing area.
3.
**Describe the process for physicians to access the dictation system/equipment and the types of reports dictated.
4.
Who provides dictation training for new physicians?
5.
**What is the expected turnaround time for the various transcribed reports and how this is monitored?
6.
Which additional services are provided by the transcription department (e.g. radiology, pathology, etc.)
7.
Who monitors the completion of dictated reports?
8.
**Describe the process for researching reports “rejected” due to incorrect patient identifying data.
9.
**How are “blanks” (non-audible dictated segments) handled? Corrected?
10. **Describe how a physician gets a transcription error corrected.
11. **Describe how dictating physicians receive/access copies of their dictation.
12. **How is the process completed for mailing/distributing copies to other physicians or healthcare providers.
13. **How are stat reports prioritized and completed?
14. **Describe the procedure for sending and receiving the reports if a contract service or at-home
transcription process is used. This includes discussing the benefits of and/or problems with using these methods.
15. **Who is responsible for handling phone calls/inquiries with questions about transcribed reports?
16. **Describe the “troubleshooting” resolution of problems involved with transcribed reports, such as incorrect patient identification on a transcribed report.
17. **Describe the process for monitoring productivity and quality.
18. **What is the billing process with an outsourced company?
26
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Assignment #13
Ergonomics Assessment of an HIM Area
Instructions: Ergonomics, also known as human factors, is the scientific discipline that seeks to understand and improve human interactions with products, equipment, environments, and systems. Drawing upon human biology, psychology, engineering, and design, ergonomics aims to develop and apply knowledge and techniques to optimize system performance, while protecting the health, safety, and well-being of individuals involved. In this assignment, students should analyze a work environment at a PPE site for ergonomics consistent with good practices. This assignment is worth 20 points
.
Expectations:
This assignment is comprised of two parts – the checklist and the summary paper.
Students will complete the following checklist based on conditions in a task area. Upon completion of their assessment, they must provide a general conclusion of the conditions evaluated with recommendations in a summary paper.
The summary paper should be a minimum of 2 pages in length (1-inch margin, double spaced,
11 or 12-point font, Arial preferred) and contain evaluative comments and recommendations concerning:
o
The organization of the work area.
o
An evaluation with recommendations of the overall environment.
o
An evaluation with recommendations of the workstations including computer monitors with keyboards.
The checklist must be word processed (no handwritten submissions accepted):
o
Students may copy and paste this questionnaire into a new document, save it as a .docx, and continue typing the summary at the end of the checklist.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes
.
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Assignment #13
Part 1: Ergonomics Assessment of an HIM Area Checklist
Student Name:
Facility: Task Area (i.e., ROI, coding, scanning, etc.): Date of Assessment: ORGANIZATION OF WORK AREA
YES
NO
SPACE
1.
Work surface and work area large enough to hold materials and equipment and perform required tasks.
☐
☐
2.
Storage space adequate for copies, handbooks, documents, and notebooks.
☐
☐
3.
Area under desk free of obstructions.
☐
☐
4.
Area under work surface provides sufficient depth, height, and width for legs to move about freely.
☐
☐
JOB AIDS AND EQUIPMENT POSITIONING
1.
Job aids (coding books, etc.) and materials placement allows efficient flow of work.
☐
☐
2.
Items used frequently (telephone, calculators, etc.) within easy reach
without extensive body movement.
☐
☐
3.
Document holder available and positioned to avoid frequent eye and head movement.
☐
☐
4.
Cables and cords positioned to prevent tripping.
☐
☐
5.
Headset available for high volume telephone use.
☐
☐
BODY POSTURE FOR SEATED POSTION
1.
Lower back support.
☐
☐
2.
Thighs approximately horizontal.
☐
☐
3.
Lower part of leg approximately vertical.
☐
☐
4.
Keyboard height allows forearms and wrists to be in a neutral (straight) position.
☐
☐
5.
Monitor at least 12-18" away from worker.
☐
☐
6.
Top of monitor screen approximately eye level.
☐
☐
7.
Mouse positioned to allow forearm and wrist to be in a neutral position.
☐
☐
8.
Feet rest flat on floor, or footrest provided, when needed.
☐
☐
9.
No prolonged forward bending.
☐
☐
10.
Minimum amount (or infrequent) bending or twisting of the back, head, or neck.
☒
☐
CHAIR
CHAIR FEATURES
1.
Stable with five-point base (safe from tipping over).
☐
☐
2.
Castors appropriate for safe mobility on floor surface.
☐
☐
3.
Swivels.
☐
☐
4.
Seat dimensions.
a)
Seat pan 15" - 19" deep
☐
☐
b)
Seat pan minimum 18.2" wide
☐
☐
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5.
Has armrests
☐
☐
a)
Good fit for user
☐
☐
b)
Clearance under work surface for arm rests
☐
☐
6.
Rounded front edge to avoid thigh pressure
☐
☐
7.
Padded seat
☐
☐
8.
Lumbar support in backrest
☐
☐
9.
Guidance/training for users describing how to make adjustments
☐
☐
CHAIR ADJUSTABILITY
1.
Chair allows user to assume different postures
☐
☐
2.
Seat height adjusts between 16" - 20.5"
☐
☐
3.
Adjustable armrests
☐
☐
4.
Adjustable height of backrest
☐
☐
5.
Backrest adjustable forward/backward
☐
☐
6.
Adjustments easily made from seated position
☐
☐
OVERALL ENVIRONMENT
1.
Lighting adequate for tasks
☐
☐
2.
Display screen free of glare and reflections
☐
☐
3.
Screen at right angle to windows
☐
☐
4.
Screen character brightness at a comfortable level
☐
☐
5.
Room temperature constant between 70 – 73 degrees
☐
☐
6.
Noise level: a)
Low due to the fact that coding requires a high level of concentration
☐
☐
b)
Environment free from distracting high noise levels (from printers, copiers, etc.)
☐
☐
7.
Environment free of hot or cold areas, e.g. under desks, in corners, etc.
☐
☐
COMPUTER MONITORS & KEYBOARD
MONITOR
1.
Large enough for adequate visibility – at least a 20-inch monitor is sufficient
☐
☐
2.
The angle and tilt should be easily adjustable
☐
☐
3.
Flat panel displays are the most suitable
☐
☐
KEYBOARD
1.
Adjustable or split keyboards
☐
☐
2.
Cord that plugs into the CPU should be long enough to allow the user to place the keyboard and the CPU in a variety of positions. At least a 6-foot length is desirable
☐
☐
3.
Built-in wrist rests allow for the most comfort
☐
☐
Remember to complete the Summary, which is the 2
nd
part
of this assignment. 29
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Assignment #14
Electronic Health Record Questionnaire
Instructions: Students should spend time with the Information Technology (IT) individuals who support the electronic health record at a healthcare facility. Students should use the questionnaire on the next page to guide them in some pertinent information about the EHR, EHR support and other EHR processes that affect the HIM department. A copy of the Electronic Health Record Questionnaire
follows. Students may print the questionnaire to take notes as they participate in the statistics process. This assignment is worth 20 points
.
Expectations
:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single- spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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Assignment #14
Electronic Health Record Questionnaire
Student Name:
Facility Name:
Presenter’s Name:
IT/EHR Support
1.
Is this facility currently utilizing an electronic health record? If so, what is the name of the EHR? Describe the system and when was the system implemented.
2.
Describe your role (and your team’s role) in support of the EHR?
3.
Is your department split into teams? If so, describe the various teams, their roles and job qualifications.
4.
Describe how the different teams/functions interact with each other.
5.
If there is a team dedicated to the HIM functions, describe the skills and background of the team members.
6.
Describe the interaction between the HIM support team and the HIM users.
7.
Who is responsible for coordinating EHR updates (process to schedule and how are the team members selected who will support the updates)?
8.
When updates are scheduled, describe the plan and processes that occur in preparation for the update.
9.
After an update occurs, describe the plan and processes that occur after an update.
10. How has the EHR affected the management of the HIM department (consider managing fewer employees, remote meetings, training, and communication)?
11. How is the EHR training provided for new facility employees? How is EHR training provided for HIM employees specifically focused on HIM functions/processes?
12. How often are EHR passwords changed?
13. Does the facility have or offer any of the following?
Electronic registration, admissions, discharge, and transfer
Electronic laboratory information systems
Electronic radiology information systems
E-prescribing
Computerized physician order entry (CPOE)
Electronic clinical documentation
Front-end speech recognition and back-end speech recognition
Personal health records
Picture archiving and communication system (PACS)
Computer-assisted coding software
Patient portal to obtain records
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EHR and the HIM Department
14. Are there ongoing committees to discuss the EHR, its processes, and possible improvements?
Provide the names of the committees and explain the roles of each of them. Indicate the staff members from the HIM department that are involved in these committees and their role.
15. What types of information technology background do staff members need to work with the electronic health record in the HIM area?
16. What have been the biggest changes in the HIM department and its functions since the implementation?
17. Explain a work queue. If possible, provide examples of work queues…for example, coding work queue, DNFB work queue…
18. List the HIM advantages/disadvantages realized by the use of the EHR.
19. If this facility has remote employees (i.e. employees that work from home) what are the policies for this situation (i.e. are home inspections required to assure appropriate privacy/security requirements, can employees print from the EHR, who pays for the PC, who pays for the internet service, PC support, required software, etc?)
20. Who did you meet with primarily to obtain answers to the above questions? Please provide the name and title of the individual.
21. As a student (from your personal experience), what do you see as the advantages and disadvantages of an EHR? What are the advantages and disadvantages to society as a whole?
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Assignment #15
Job Procedure
Instructions: Students should write a job procedure for a task or job function within the HIM department by observing/participating in the process and then writing the procedure based on the observations and discussion. The employee(s) in the task or job function may review the procedure for completeness. The procedure should be created in the standard format taught in HIM 2145, unless
the PPE Site Supervisor requests otherwise. The student must not
have access to the previously written procedure but may see the format of other departmental procedures. This assignment is worth
20 points
.
Expectations:
Your report reflects the correct sequence and appropriate description of the procedure.
Your report must follow the facility’s procedure format or follow the HIM 2145 procedure format.
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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Assignment #16
Privacy Officer/HIPAA Questionnaire
Instructions:
Protecting and safeguarding protected health information is an increasingly complex job. HIPAA mandates that each Covered Entity designate a HIPAA Privacy Officer. Students must be aware of this position and the many responsibilities that come along with the position. Students should use the questionnaire on the next page to guide them in interviewing a Privacy Officer. A copy of the Privacy Officer/HIPAA Questionnaire
follows. Students may print the questionnaire to take notes as they participate in the statistics process. This assignment is worth 20 points
.
Expectations:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single-
spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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Assignment #16
Privacy Officer/HIPAA Questionnaire
Student Name:
Facility Name:
Presenter’s Name:
1.
Name of the Privacy Officer: 2.
Who does the Privacy Officer report to at the facility?
3.
What are the educational qualifications of the Privacy Officer?
4.
Was the Privacy Officer previously employed by the facility?
5.
How long has the Privacy Office been employed as the Privacy Officer?
6.
List the major responsibilities of the position and explain them in detail.
7.
On what committees does the Privacy Officer serve, and in what capacity?
8.
How does the Privacy Officer stay up to date with the latest developments and changes in HIPAA regulations and privacy laws?
9.
What types of educational programs have been initiated by the healthcare facility to educate employees about HIPAA? 10. Explain the fundamental principles of the Health Insurance Portability and Accountability Act (HIPAA) and its significance in healthcare privacy and security?
11. HIPAA mandates that organizations have written policies and procedures for handling PHI. How does the Privacy Officer go about developing and maintaining these policies, and how does the Privacy Officer ensure that staff members adhere to them?
12. In the event of a data breach or a security incident involving PHI, what steps would the Privacy
Officer take to investigate, mitigate, and report the incident in compliance with HIPAA requirements?
13. As the Privacy Officer, can you provide an example of a challenging situation you've encountered related to HIPAA compliance in your role? How did you handle it, and what was the outcome?
14. In what ways is the Privacy Officer involved with the HIM Department?
15. In what ways is the Privacy Officer involved with the Medical Staff?
35
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16. How does the Privacy Officer work with the Security Officer (IT)?
17. In what ways is the Privacy Officer involved with the facility administration?
18. In what ways is the Privacy Officer involved with the facility's legal counsel?
19. What types of compliance monitoring activities take place at the facility?
36
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Assignment #17
Cancer Registry and the Oncology Data Specialist
Instructions:
The data from facility-based Cancer Registries are used to provide information for the improved understanding of cancer, including its causes and methods of diagnosis and treatment. In addition, the data may also provide comparisons in survival rates and quality of life issues for patients with different treatments at different stages of cancer.
Students may have the opportunity to participate in a presentation by an Oncology Data Specialist (previous name: Cancer Registrar). Throughout this presentation, students are encouraged to take notes and ask questions. This assignment is worth 20 points
.
Expectations:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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Assignment #18
Charge Description Master Questionnaire
Instructions: The charge description master (CDM) or chargemaster is an important process used in hospitals in charging for routine services and supplies provided to each patient. The data gleaned from the chargemaster function is important for many other processes within the facility. Students should explore this job function using the CDM Questionnaire.
A copy of the Statistics Questionnaire follows. Students may print the questionnaire to take notes as they participate in the CDM presentation. However, once the data is gathered, students should copy the questionnaire and paste it into a new word-processing document to complete it. This assignment is worth 20 points
.
Expectations:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single- spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
38
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Assignment #18
Charge Description Master Questionnaire
Prior to the CDM presentation, students should complete questions 1 and 2 on this questionnaire.
1.
Briefly describe a charge description master (chargemaster)
2.
What are some of the reasons why a CDM should be reviewed and updated on a regular basis?
3.
Who at this facility is in charge of the overall integrity of the charge description master?
4.
What is this person's title?
5.
What is this person's professional background?
6.
Is the review of the CDM a "team" approach?
7.
If yes, list the members of the team and explain their role.
8.
How often is the CDM review process completed?
9.
What resources are utilized when updating the CDM and what are the CDM team responsibilities?
10. Is there a periodic CDM review at this facility by an external consulting firm?
11. If so, please explain.
12. Describe the role of the HIM department in a CDM review.
13. Describe how accurate coding plays a role in the CDM maintenance in this facility.
14. The CDM has many uses and serves as a database. Please name a few of the uses for a CDM.
15. Explain the Price Transparency Rule.
16. Give an example of a procedure where codes are supplied by the use of a CDM (example: some cardiac catheterization codes are supplied by the CDM, and some must be assigned by the coder)
17. What are your overall feelings about how the CDM process works at this facility? If possible, please list 5 codes and their narrative description currently in the facility's CDM. Please use a CPT code book to verify that the code number in the CDM is consistent with the code in the CPT code book. Indicate any verifications and/or discrepancies. 39
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Assignment #19
Job Description
Instructions: Students should write a job description for a position within the HIM department. The choice of the position can be a joint one between the student and the PPE supervisor. Students should interview the staff member and observe the position; then write the description based upon the
observation and interview. The job description should be created in the standard format taught in HIM
2145, unless the PPE Supervisor requests otherwise. (If the student needs the HIM 2145 format, the PPE Supervisor can provide it.) Students must not
have access to the previously written job description but may see the format of other departmental job descriptions. The Physical Abilities Chart should be attached as the last page of the job description even if the job description format used is specific to the HIM department. This assignment is worth 20 points
.
Instructions for Students:
Students must submit a word-processed document with the following Evaluation Criteria Sheet attached as the first page of the job description. The Physical Abilities Chart is attached as the last page of the job description.
Expectations:
Your report reflects the appropriate description of the position.
Your report must follow the facility’s job description format or follow the HIM 2145 procedure format.
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
40
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Physical Abilities Chart
Job Title: Please place an X in the column that best indicates the percentage of physical requirements necessary for each activity. Physical Requirements
1 = Rarely (0% - 10%)
2 = Occasionally (11% - 40%)
3 = Frequently (41% - 75%)
4 = Consistently (76% - 100%)
ACTIVITY
1
2
3
4
ACTIVITY
1
2
3
4
ACTIVITY
1
2
3
4
Walking
Standing
Hearing in Both Ears
Normal
Sitting
Reaching
Other Sounds
Pushing
Manual Dexterity
Vision
Acuity, Near
Pulling
Use of Both Hands
Acuity, Far
Climbing
Talking
Color Vision
Stooping
Lifting over 50 lbs.
Kneeling
Lifting under 50 lbs.
Additional Comments:
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Assignment #20
RAC Coordinator/Manager Questionnaire
Instructions:
The Recovery Audit Contractor (RAC) Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states. Recovery audit contractors (RAC) are charged with recovering improper Medicare payments to providers. Students will complete the RAC Coordinator/Manager Questionnaire.
Students may have the opportunity to participate in a presentation by the RAC Coordinator/Manager, the healthcare facility’s representative who coordinates the facility’s process in these activities. Throughout the presentation, students should explore the management of associated work processes,
volume of medical record requests, types of denials, appeals processes, and data sharing among key members in the organization. Students are encouraged to take notes and ask questions. A copy of the RAC Coordinator/Manager Questionnaire follows. Students may print the questionnaire to take notes as they participate in the presentation. However, once the data is gathered, students should copy the questionnaire and paste it into a new word-processing document to complete it. This assignment is worth 20 points
.
Expectations:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single- spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
42
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Assignment #20
RAC Coordinator/Manager Questionnaire
Student Name:
Facility Name:
Presenter’s Name:
1.
Name and credentials of the RAC Coordinator/Manager 2.
Who does the RAC Coordinator/Manager report to at the facility? 3.
What are the educational qualifications of the RAC Coordinator/Manager? 4.
What are the major responsibilities of this position?
5.
What meetings does the RAC Coordinator/Manager attend and how often? What kind of information is discussed at the meetings?
6.
How does the RAC Coordinator/Manager maintain current knowledge of CMS/Medicare and RAC regulations? (websites, newsletters, conferences) 7.
How is information shared with others and how does the facility educate employees about RAC?
8.
What is the name of the organization that is the current RAC contract holder for your PPE site? 9.
With which departments does the RAC Coordinator/Manager communicate/correspond?
HIM
CFO/VP Finance
Billing (PFS)
Administration
Charge master
Medical Director
Compliance
UR Committee
Case Management/Denials Management
Coding
Legal Counsel
Clinical Staff
Other, please list:
10. List any other interesting information concerning the RAC Coordinator or the RAC process at this facility.
11. Ask the RAC Coordinator/Manager what other questions/answers he/she thinks should be included in this questionnaire.
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Assignment #21
Revenue Cycle Assignment
Instructions: In courses at Sinclair, students have studied the Revenue Cycle in medical facilities. The three major components include 1) front-end processes (Patient Engagement), 2) middle processes (Resource Tracking), and 3) back-end processes (Claims Production and Revenue Collection). As the presenter describes and discusses information about the revenue cycle, students should take notes and ask appropriate questions. Students should review the Revenue Cycle process detailed in their Sinclair reimbursement course prior to the presentation. Then using the questions and talking points below for guidance, write a paper detailing the information gathered from the presentation. Throughout the presentation, students should take notes and ask appropriate questions. This assignment is worth 20 points.
Expectations
:
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
The following list of ideas/thoughts/concepts should be addressed in the assigned report. This is by no means a complete or comprehensive list of discussion points. Additional information may be included to fully describe this function.
1.
Describe the background and past job roles of the presenter.
2.
Describe the area(s) over oversight for this presenter.
3.
Describe the healthcare facilities and a bit about the network.
4.
Briefly describe the revenue cycle that occurs within this network.
5.
Describe the various parts included in the revenue cycle of this healthcare network.
6.
Describe some of the jobs/job titles within the revenue cycle of this healthcare network.
7.
Which positions interact with patients?
8.
How does price transparency fit into the revenue cycle?
9.
Are there any new initiatives on the horizon for this network that affect the revenue cycle?
10. Are there any new regulations on the horizon that affect the revenue cycle?
11. Include any other interesting information provided in this presentation.
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Assignment #22
Coding Training Questionnaire
Instructions: A copy of the Coding Training Questionnaire follows. Students may print the questionnaire to take notes. However, once the data is gathered, students should copy the questionnaire and paste it into a new word processing document to complete it. This assignment is worth 20 points.
Expectations:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single- spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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Assignment #22 Coding Training Questionnaire
1.
Who is/are the coding trainer(s) for your facility and what are their credentials?
2.
What are the qualifications needed to become a trainer?
3.
Where/how did the coding trainer(s) receive their training? 4.
Who do the coding trainers contact for more information or current coding guidelines regarding ICD-10? CPT?
5.
To whom do the coding trainers report?
6.
What are the qualifications for the coders at this facility?
7.
Describe the training process for new coders.
8.
Is the facility utilizing contract coders (outsourcing)? If so, please describe the framework and standards for these coders.
9.
Describe the communication between coding and billing.
10.
Who is responsible for training/working with the physicians for documentation improvement?
11.
Describe how coders are made aware of the financial impact their coding has on the facility.
12.
How is coding productivity configured? Describe how coders are made aware of their coding productivity? Describe the process for coding productivity.
13.
Describe the report for “Discharged, Not Final Billed” (DNFB). Who is responsible for monitoring this report?
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Assignment #23
Patient Portal
Instructions: A copy of the Patient Portal Questionnaire follows. Students may print the questionnaire
to take notes. However, once the data is gathered, students should copy the questionnaire and paste it into a new word-processing document to complete it. This assignment is worth 20 points.
Expectations:
Your answer(s) must be typed under each question/statement, 1-inch margin, answers single- spaced, double space between questions, 11 or 12-point font (Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
The following list of ideas/thoughts/concepts should be addressed in the assigned report. This is by no means a complete or comprehensive list of discussion points. Additional information may be included to fully describe this subject.
1.
List the key patient portal capabilities.
2.
Describe the key data collected in a patient portal.
3.
Define structured vs unstructured data (Hint: Text messaging is unstructured.)
4.
What security controls are in place to control and/or verify patient portal access to only the patient or other authorized individuals? (Such as passwords, double verification, etc.)
5.
How often must a patient’s portal password must be changed?
6.
Is the patient portal available via mobile app?
7.
Does the patient portal provide patient education?
8.
What type of “help” or accessibility resolutions are available for individuals with disabilities.
9.
List at least five of the benefits of patient portals: (The big goal is to improve patient outcomes.)
10. List at least five challenges of patient portals.
11. Describe the Health Information Management role in managing Patient Portal Management. 12. Explain how the 21st Century Cures Act affected the Patient Portal policies and procedures.
13. Describe how access to a minor patient’s record is handled. What if the biological parents are divorced?
14. If an individual is a healthcare POA for a patient, how is access to the patient’s portal handled?
15. Explain how a data breach is processed. For example, an Ambulance Run Sheet has been scanned into the wrong patient’s record and it has now been reviewed by the incorrect patient.
16. Who helps patients access their patient portal?
17. Who help patients with password issues?
18. Are eVisits (medical assistance to patients via patient messaging) billable? If so, provide details.
19. Does the facility collect data for patient portal usage?
20. Determine the role HIM professionals play in the patient portal in this healthcare facility.
21. Are there any current challenges that are being evaluated and/or addressed?
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Assignment #24
Other Presentation Topics There is a great deal of flexibility built into this portion of PPE concerning presentations offered. When
a presentation is not included in Assignments #1-23 above. This is not a research paper; it is a reflection of the information provided in the presentation. Remember, your report must meet the below
criteria. Remember, a report of less than 2 pages will warrant a hefty deduction of points.
Your report reflects the data and information presented.
The presenter’s name must be included in the report.
Your report must be typed, 2-3 pages in length, 1-inch margin, double spaced, 11-12-point font
(Arial preferred).
The document is saved as a .docx file.
Include the Evaluation Criteria Coversheet (with the top portion completed) as the first page of the document. This Coversheet is located in the first few pages of this packet.
Your report must be submitted in one of the Professional Presentation PPE drop boxes.
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A department adds materials at the beginning of the process and incurs conversion costs uniformly throughout the process. For the
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ip
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